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TREATISE 


ON  THE 

DISEASES  AND  SPECIAL  HYGIENE 


FEMALES. 


BY  COLOMBAT  DE  L’ISERE. 


TRANSLATED  FROM  THE  FRENCH,  WITH  ADDITIONS. 


BY  CHARLES  D.  MEIGS,  M.D. 

Prof,  of  Midwifery  and  the  Diseases  of  Women  and  Children  in  Jefferson  Med.  Col.,  Philad.; 
Member  of  the  Amer.  Philos.  Society;  of  the  Philad.  Col.  of  Physicians; 
of  the  Philad.  Med.  Society;  and 
Physician  to  the  Lying-in  Department  of  the  Penn.  Hospital. 


WITH  WOOD  CUT  ILLUSTRATIONS. 


PHILADELPHIA: 

LEA  AND  BLANCHAKD. 

1845. 


Us 


V 


Entered  according  to  the  Act  of  Congress,  in  the  year  1845,  by 
LEA  AND  BLANCHARD, 

in  the  Clerk’s  Office  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  Pennsylvania. 


T.  K.  (Sc  P.  G.  COLLINS,  Printers,  No.  1 Lodge  Alley 


r~ 

X 

{ 

M 

c 

I 


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A 


TO  R.  LA  ROCHE,  M.D. 


My  dear  Friend — 

i 

I have  translated  the  very  learned  work  of  Mons.  Colombat  de 
L’Isere,  and  have  added  to  it,  in  the  form  of  notes,  printed  Avithin 
brackets  in  the  body  of  the  text,  about  one  hundred  pages  of  original 
matter,  constituting  nearly  a seventh  part  of  the  volume.  I dedicate 
my  labour  to  you ; and  I beg  you  to  accept  even  this  small  offering 
to  a friendship  which  is,  and  has  been  for  many  years,  a large  part 
of  my  happiness. 

You,  who  know  what  a hurried  and  toilsome  life  I lead,  will,  on  that 
account,  perhaps  as  well  as  out  of  your  constant  grace  and  goodness  to 
me,  be  ready  to  overlook  such  faults  of  style,  and  such  typographical 
errors,  as  have  crept  into  the  pages;  the  more  especially,  seeing  that 
I have  written  them  out,  corrected  the  proofs,  and  revised  them,  for 
the  most  part,  after  midnight,  while  engaged  in  practice,  and  during 
my  course  of  Lectures  at  the  college : I say  for  the  most  part,  since 
my  son,  Dr.  Meigs,  has  assisted  me  in  a portion  of  the  translation. 
These  excuses  for  faults,  probably  the  critical  public  will  not  accept ; 
If  you  should  accept  them,  however,  I shall  rest  under  the  hope 
that  they  also  will  admit  them,  and  readily  acknowledge  the  good 
service  I have  done  in  laying  before  them  so  excellent  a treatise. 
Mons.  Colombat,  by  his  elaborate  and  judicious  collation  of  authori- 
ties, of  whom  more  than  one  thousand  are  here  cited,  on  topics  rela- 
tive to  the  objects  of  the  treatise,  has  produced  a complete  exposition 
of  the  opinions  and  practical  methods  of  the  celebrated  practitioners 
of  ancient  and  modern  times;  and  his  work  comprises  a body  of 
knowledge  most  important  in  this  country.  I cannot,  therefore,  but 
hope  that  I may  even  be  favourably  received  by  our  brethren,  who 
now  enjoy  the  benefits  of  M.  C.’s  enormous  toil. 

I refer  you  to  M.  Colombat’s  introductory  pages  for  a statement 
of  his  motives  and  his  method  as  to  this  work — trusting  that  you 
will  find  in  it  the  plan  of  a capital  performance,  which,  as  the 
perusal  of  his  pages  may  serve  to  show,  has  been  fully  carried  out. 


IV 


DEDICATION. 


As  a text  and  table  book  for  the  student  and  practitioner,  I do  not 
think  it  has  an  equal  in  its  department. 

As  to  the  materials  that  I have  contributed,  I hope  you  will  give 
your  approbation  to  the  notices  on  the  Hsematological  Disorders,  and 
also  to  my  remarks  upon  Puerperal  J^ever,  concerning  which  many 
vague,  incompetent  and  unsettled  notions  seem  to  prevail  on  both 
sides  of  the  Atlantic.  I confess  myself  as  wholly  belonging  to  the 
party  of  the  Gordons  and  Heys,  who  have  been  so  strenuous  in 
their  advocacy  of  a sound  pathology  and  therapeia  of  the  terrible  dis- 
ease in  question.  You  will  see  that  in  some  places  I disagree  with 
M.  Colombat,  and  even  enter  my  protest  against  his  views ; but  I 
can  never,  even  under  such  circumstances,  feel  other  sentiments  than 
those  of  a profound  respect  for  an  author  who  has  effected  so  much. 

In  one  of  the  pages  of  his  Hygiene,  M.  C.  says  that  women 
are  not,  by  their  nature  and  position,  fitted  to  shine  in  the  walks  of 
literature,  nor  to  toil  for  a scientific  reputation,  which  men,  even, 
cannot  acquire  but  at  the  expense  of  their  health  and  their  happi- 
ness. Alas!  I am  grieved  to  learn  that  the  estimable  author  of 
the  Treatise  presents,  in  his  own  person,  the  confirmation  of  his 
assertion ; and  that  his  ruined  health  may  be  traced  to  the  untiring 
zeal  with  which  he  has  pursued  “ the  bubble  reputation,”  and  a 
more  solid  advantage,  to  wit,  a consciousness  of  having  done  a good 
work  for  his  day  and  generation.  Join  with  me  in  sincere  wishes 
that  it  may  please  the  Divine  Providence  to  restore  his  health,  and 
that  he  may  again  be  able  to  exert  his  inexhaustible  patience,  skill 
and  probity,  in  behalf  of  an  art  which  such  talents  are  well  qualified 
to  illustrate  and  adorn. 

Farewell,  my  dear  friend,  and  believe  that  I am,  always, 

Your  grateful  and  affectionate 

CH.  D.  MEIGS. 


INTRODUCTION. 


Medicina  non  ingenii  humani  partus  est, 

Sed  temporis  filia.  i Baglivi. 

In  obedience  to  the  unchangeable  law  of  nature,  and  in  fulfil- 
ment of  the  common  destiny  of  organic  beings,  the  female,  like  the 
male,  lives  under  subjection  to  the  various  revolutions  of  existence; 
like  him  she  is  born,  grows  up,  becomes  feeble  and  perishes ; like 
him  she  passes  through  all  her  phases,  and  attains  the  fatal  term, 
after  having  been  constantly  under  the  influences  of  the  varied 
causes  that  are  capable  of  affecting  the  health  of  the  body.  But 
although  both  sexes  are  alike  exposed  to  a variety  of  maladies,  the 
number  of  ills  that  overwhelm  them,  is  not  alike,  for  to  the  too 
numerous  evils  which  woman  participates,  as  a common  lot  with 
man,  nature  has  superadded  all  those  that  take  their  rise  in  the 
superior  excitability  of  her  nervous  system,  and  in  those  painful  and 
stormy  functions  which  prepare  her  for  the  power,  or  for  the  act  of 
reproduction. 

If  it  be  true,  as  Bischat  says,  that  lesions  are  most  frequent  in  parts 
where  action  is  greatest,  if  each  organ  is  liable  to  be  affected  in  the 
direct  ratio  of  its  degree  of  activity,  there  is  no  occasion  for  us  to  be 
surprised  ~at  the  frequency  and  variety  of  the  maladies  to  which  the 
womb  is  subject.  The  extreme  sensibility  of  that  viscus,  its  phy- 
siological importance,  its  peculiar  irritability,  and  especially  its  more 
or  less  intimate  sympathetic  connection  with  other  parts  of  the  body, 
render  it  a centre  of  action,  which  in  the  sex  seems,  in  a measure, 
to  domineer  over  the  whole  economy,  and  form  the  principal  basis 
upon  which  the  edifice  of  the  organization  rests.  It  is  easy,  from 
what  we  have  just  said,  to  explain  why  the  vital  lesions  of  the  womb 
and  its  appendages  rarely  exhibit  themselves  at  the  two  extremes 
of  existence,  but  are  very  frequent  at  the  season  of  the  cessation  of 
the  menses,  and  especially  throughout  the  whole  term  of  years  dur- 
ing which  the  genital  organs  are  subject  to  periodical  states  of  exci- 
tation, as  well  as  to  other  excitements  of  various  kinds. 


VI 


INTRODUCTION. 


All  these  disorders,  the  number  of  which  Democritus  exaggerated 
in  his  letter  to  Hippocrates,  in  which  he  says  “ Uterus  sexcent arum, 
aerumnarum  in  mulieribus  causa,”  all  these  disorders  are  much 
better  understood  in  modern  than  they  were  in  ancient  times.  Our 
ideas  in  regard  to  their  nature,  causes  and  treatment,  are  more  pre- 
cise in  the  present  age,  because  in  their  search  after  truth,  the  medi- 
cal men  of  the  present  period  are  guided  by  a more  rigorous  analysis 
of  symptoms,  and  have  liberated  themselves  from  the  rusty  chains 
of  the  doctrines  of  the  ancients,  by  embracing  the  sources  of  positive 
knowledge  found  in  the  sciences  of  physics,  chemistry,  and  patho- 
logical anatomy. 

Notwithstanding  the  whole  circle  of  diseased  conditions  is  com- 
prised within  the  domain  of  medicine,  and  though  it  is  the  bounden 
duty  of  the  physician  to  consecrate  his  studies  and  meditations  to  the 
discovery  of  prophylactic  and  therapeutical  methods  that  may  serve 
to  prevent  them  all,  or  conduct  them  with  greater  or  less  celerity  to 
a radical  cure,  they  cannot  all  be  equally  the  objects  of  his  profound 
research;  they  cannot  all  alike  exercise  his  talent  for  investigation ; 
he  must  direct  his  attention  especially  to  those  which,  like  most  of 
the  diseases  of  the  womb,  indeed,  have  been  imperfectly  studied,  and 
are  in  some  sort  known  only  by  their  disastrous  effects. 

In  spite  of  the  progress  of  the  human  mind,  and  the  numerous 
conquests  that  have  been  made  in  every  department  of  medical 
science,  there  is  much  still  to  be  said,  and  a great  deal  to  be  done, 
and  a brilliant  task  remains  to  be  fulfilled.  Multum  rest  at  adhuc 
operis,  multumque  restabit,  nee  ulli  nato  post  mille  saecula,  prse- 
cludetur  occasio  aliquid  adjiciendi.  Seneca,  lib.  i.  epist.  lxiv. 

If,  on  the  one  hand,  we  reflect  upon  the  real  improvements  in  the 
medico-chirurgical  therapeutics  of  the  diseases  of  the  womb,  which 
have  lately  been  introduced  by  the  new  methods  of  diagnosis ; and, 
on  the  other  hand,  consider  that  all  the  treatises  upon  diseases  of 
women  are  in  several  regards  incomplete,  or,  at  least,  far  from  being 
up  to  the  level  of  the  times,  we  shall  be  able  to  appreciate  the  useful- 
ness, and  even  the  necessity  of  a work  that  may  contain,,  although 
within  a narrow  compass,  every  thing  relating  to  this  interesting  sub- 
ject. It  is  with  the  hope  of  filling  up  this  vacuum,  and  with  the 
intention  of  being  serviceable,  both  to  practitioners  and  pupils,  that 
the  present  treatise  is  published;  a treatise  which  comprises  an 
account  of  the  physiology,  the  surgical  anatomy,  pathology,  thera- 
peutics, operative  medicine  and  hygiene,  of  the  genito-mammary 
organs  of  the  sex. 


INTRODUCTION. 


Vll 


We  have  been  aware  of  the  extent  and  difficulty  of  our  enterprise. 
In  venturing  to  undertake  it,  notwithstanding  the  numerous  diffi- 
culties in  our  path,  we  have  been  influenced  less  by  any  confidence 
in  our  own  ability,  than  by  the  attraction  of  the  powerful  interest  of 
a subject,  to  which  we  have,  during  the  last  ten  years,  consecrated 
a major  portion  of  our  studies  and  researches.'* 

The  division  we  have  adopted,  is  founded  upon  the  analogies  ob- 
served between  the  maladies  whose  history  is  comprised  within  our 
plan : with  a view  to  facilitate  the  study  of  them,  and  particularly 
with  the  design  of  grouping  and  approximating  them  as  closely  as 
possible,  in  the  natural  order  they  ought  to  occupy  in  any  general 
system  of  pathology,  we  have  divided  them  into  six  sections,  to 
wit:  1.  lesions  of form ; 2.  lesions  of  situation;  3.  -physical  lesions; 
4.  vital  lesions;  5.  lesions  of  the  functions;  6.  lesions  relative  to 
reproduction. 

In  the  first  section,  which  comprises  all  the  primitive  and  the  acci- 
dental deformities,  we  have  entered  more  into  detail  than  any  of  our 
predecessors,  and  endeavoured  more  distinctly  to  point  out  the  various 
lesions  connected  with  the  coherence,  imperforation,  obliteration,  nar- 
rowness, obturation,  and  all  the  different  kinds -of  genito-urinary 
occlusion  in  the  female.  After  relating  and  criticizing  a great  number 
of  curious  cases,  and  after  having  indicated  all  the  diagnostic  and  the- 
rapeutical methods  appropriate  to  these  different  lesions,  we  pointed 
out  a very  simple  mode  of  perforating  the  membrana  hymen , at  the 
same  time  preserving  it  as  far  as  possible,  on  account  of  the  moral 
importance  attached  to  its  existence,  and  allowing  of  a gradual  dis- 
charge of  the  menstrual  products  accumulated  within  the  womb,  and 
avoiding  as  completely  as  possible,  the  pernicious  effects  of  air,  when 
introduced  into  the  cavity  of  the  viscus.  We  have  also  proposed  a 
new  method  of  curing  congenital  narrowness  of  the  vagina,  and 
have  given  a figure  of  a cutting  thimble,  and  a knife  with  a very 
convex  edge,  for  separating  the  coherent  sides  of  the  vagina. 

In  the  second  section  we  have,  in  considerable  detail,  treated  of  the 
various  prolapsions  of  the  womb ; and  founding  our  opinions  upon  a 
great  number  of  observed  cases,  we  have  pointed  out  in  a more  com- 
plete manner,  the  advantages  and  disadvantages  of  the  various  kinds 

* Having  been  resident  surgeon  of  the  Maison  de  Sante,  of  the  Rue  de  Valois  du 
Roule,  specially  appropriated  to  the  medico-chirurgical  treatment  of  the  diseases  of 
women;  and  having,  for  a long  time,  attended  the  learned  clinics  of  Dupuytren,  and 
of  Messrs.  Lisfranc  and  Recamier,  &c.,  we  have  enjoyed  opportunities  of  collecting 
a great  number  of  cases  of  disorders  of  the  womb,  and  its  appendages,  which  we 
made  the  subjects  of  a memoir  in  the  year  1828. 


INTRODUCTION. 


viii 

of  pessaries  in  use,  and  of  other  palliative  and  curative  measures 
scarcely  treated  of  by  other  authors  on  the  diseases  of  women.  We 
have,  likewise,  made  efforts  to  omit  nothing  important  relative  to  the 
deviations,  the  incurvations,  the  inversion,  elevation  and  immobility 
of  the  uterus ; the  different  hernias  of  the  organ,  as  well  as  of  the 
ovaria ; the  prolapsus  of  the  lining  membrane,  and  the  invagination 
of  the  vagina;  in  fine,  the  prolapsus  and  thickening  of  the  lining 
membrane  of  the  urethra;  while  the  vulvar  and  vaginal  cystoceles  and 
enteroceles  have  been  particularly  the  objects  of  our  close  attention. 

In  the  third  section,  which  comprises  all  the  solutions  of  continuity, 
the  contusions,  the  wounds  and  lacerations ; the  ruptures  of  the 
vulva,  of  the  perineum*  the  vagina,  and  the  womb ; the  contusions 
and  wounds  of  the  breast,  and  in  fine,  the  introduction  of  foreign 
bodies  into  the  genital  cavities,  we  have  proposed  various  instru- 
ments to  facilitate  and  ensure  the  surgical  operations  required  by 
these  lesions,  especially  the  vaginal  fistulas. 

In  the  fourth  section,  which  alone  consists  of  near  two  hun- 
dred pages,  and  in  which  are  collected  the  different  phlegmasias, 
acute  and  chronic,  superficial  or  deep-seated ; the  transformations, 
the  degenerations  and  all  the  morbid  productions  of  the  vulva,  the 
vagina,  the  uterus,  the  ovaries  and  the  mammae,  we  have  made 
known  several  instruments  of  our  own  invention,  for  the  surgical 
treatment  of  the  polypous  tumours  and  cancerous  affections  of  these 
organs.  For  the  purpose  of  facilitating  a comparison  and  impar- 
tial judgment  of  the  measures  we  have  proposed,  we  have  men- 
tioned and  described  with  equal  fidelity,  most  of  those  that  have 
been  employed  by  other  medical  men  ; and  we  were  prevented  from 
giving  figures  along  with  the  descriptions  of  the  operative  proceed- 
ings, merely  by  the  consideration  that  most  of  them  are  already  of 
no  recent  date,  and,  therefore,  generally  known. 

In  the  fifth  section,  not  only  have  we  endeavoured  to  forget 
nothing  relating  to  the  functional  lesions  and  the  neuroses  peculiar  to 
females,  but  we  have  advanced  some  new  ideas  on  the  causes,  the 
diagnosis  and  treatment  of  uterine  haemorrhage,  amenorrhoea,  chlo- 
rosis, nymphomania  and  hysteria. 

We  pass  in  silence  by  the  sixth  section,  which  figures  in  our 
synoptical  table  of  the  diseases  of  women,  because  it  comprises  those 
lesions  that  are  relative  to  reproduction,  which  do  not  enter  into  the 
plan  of  the  present  work,  and  which,  moreover,  are  of  sufficient 
importance  to  induce  us  to  consecrate  to  them  a special  Treatise, 
wholly  independent  of  the  present  one. 


INTRODUCTION. 


IX 


To  complete  our  prefatory  sketch  of  the  plan  of  this  volume,  let 
us  remark,  that  previously  to  entering  properly  upon  our  task,  we 
have  given,  1.  Four  chapters,  comprising  the  history  of  the  physical, 
moral  and  physiological  changes  that  occur  in  women  at  different 
periods  of  life.  2.  The  varieties  of  conformation;  the  surgical 
anatomy  of  the  sexual  organs,  and  the  sympathies  of  the  womb. 
3.  The  different  methods  of  exploration  of  the  genitalia,  and  the 
history  of  the  speculum  uteri.  4.  The  general  causes  and  a synop- 
tical table  of  the  diseases  of  females.  It  should  be  likewise  ob- 
served, that  our  anatomical  and  physiological  details  are  confined  to 
considerations  applicable  directly  to  pathology  and  therapeutics. 
Under  the  conviction  that  all  epochs  and  all  nations  are  tributary  to 
medicine,  and  that  to  shut  up  this  noble  science  within  the  narrow 
boundaries  of  an  age -or  a nation,  is  to  do  it  injustice,  we  have 
neglected  none  of  the  materials  furnished  by  antiquity,  by  the 
middle  ages,  and  by  cotemporary  medicine  of  all  countries.  It  will 
be  perceived,  that  in  stating  a variety  of  opinions,  of  experiments, 
and  of  curious  cases,  scattered  throughout  many  volumes,  numerous 
collections,  and  French  and  foreign  journals,  we  have  scrupulously 
quoted  the  sources  whence  they  were  obtained.*  Lastly,  in  order 
to  render  our  work  as  complete  as  possible,  we  have  brought  it  to  a 
conclusion  by  a long  chapter  on  the  special  hygiene  of  the  female  ; 
and  hoping  thereby  to  secure  the  better  attention  of  the  reader, 
and  especially  to  lessen  the  dryness  of  the  descriptions,  we  have 
intercalated  throughout  the  whole  extent  of  the  work,  historical  facts 
and  many  curious  and  interesting  cases. 

Notwithstanding  all  our  efforts  to  succeed  and  leave  no  gap  unoc- 
cupied, we  are  far  from  supposing  this  treatise  to  be  equal  to  our 
wishes : that  is  to  say,  a *book  in  which  nothing  is  wanting ; where 
nothing  is  in  excess ; and  where  every  thing  is  in  its  proper  place. 
Should  a benevolent  criticism  point  out  the  errors  and  omissions  of 
our  work,  we  shall  be  flattered  by  it,  and  shall  the  more  gratefully 
receive  the  advice  of  the  learned,  especially  as  we  are  resolved  to 
profit  by  any  good  counsel,  even  should  it  be  dictated  by  envy,  sup- 
posing us  sufficiently  fortunate  to  awaken  such  a feeling. 

May  our  intentions  be  properly  estimated,  and  may  this  work 
obtain  the  approbation  of  our  readers ! 

“Quebso  veniam  non  laudem.” 


* The  extent  of  our  researches  will  be  understood  when  it  is  known  that  we  have 
cited  above  one  thousand  authors,  an  alphabetical  list  of  whom  is  given,  with  a view 
to  facilitate  the  history  and  literary  study  of  the  diseases  of  women. 


-i 

. 

* • . . ■ .•  t . \ 


. ' • i ' 

. 

- *■  ; 

4 

r<3 

* 

* * « a 

t 

* 

' 

CONTENTS 


Dedication,  - - - - - - - -iii 

Introduction,  ---------  y 

CHAPTER  I. 

HISTORY  OF  THE  PHYSICAL,  MORAL  AND  PHYSIOLOGICAL  CHANGES  WHICH  TAKE 


PLACE  IN  FEMALES  AT  THE  PRINCIPAL  EPOCHS  OF  LIFE.  17 

Phenomena  of  Menstruation,  -------22 

Phenomena  of  Gestation,  ------  35 

Of  the  Cessation  of  the  Menses,  ------  37 


CHAPTER  II. 

OF  VARIETIES  OF  CONFORMATION,  THE  SURGICAL  ANATOMY  OF  THE  GENITAL  ORGANS, 


AND  THE  SYMPATHIES  OF  THE  WOMB.  43 

Of  the  Vagina  and  certain  varieties  of  Conformation  observed  in  it,  - - 46 

Of  the  Womb;  its  Surgical  relations,  and  certain  Varieties  of  its  situation,  - 49 
Varieties  of  Conformation,  and  surgical  relations  of  the  Neck  of  the  Womb,  51 

Faulty  Conformation,  primitive  or  accidental,  of  the  Female  Sexual  Organs,  - 53 
Of  the  Sympathies  of  the  Womb,  - - - - - - 56 


CHAPTER  III 

EXAMINATION  OF  THE  FEMALE  ORGANS  OF  GENERATION,  BY  TOUCHING  AND  BY  THE 
. SPECULUM. 


Of  Touching  per  Vaginam,  -------  60 

Of  Touching  by  the  Rectum,  -------62 

Of  Palpation  above  the  Pubis,  or  Touching  at  the  Hypogastrium,  - - 63 

Of  the  Speculum  Uteri  and  the  manner  of  using  it,  - - - - 64 


CHAPTER  IV. 

GENERAL  CAUSES  AND  SYNOPTICAL  TABLE  OF  DISEASES  OF  FEMALES.  71 


Xll 


CONTENTS. 


. FIRST  SECTION. 

CHAPTER  V. 


Lesions  of  Form  and  Development,  ------  74 

Occlusion  of  the  Sexual  Organs,  - - - - - 74 

Of  the  Union  of  the  Labia  and  of  other  faulty  Conformations  of  the  Vulva 

and  its  parts,  - - - - - - - - 76 

Of  Cohesion  of  the  Nymphee,  -------  79 

Of  Excessive  Development  of  the  Nvmphse,  -----  80 

Of  Unnatural  Development  of  the  Clitoris,  and  of  its  Excision,  - - 82 

Imperforation  and  Stricture  of  the  Female  Urethra,  - - - 85 

Faulty  Conformation  of  tfce  Vagina,  ------  87 

Imperforation  of  the  Vagina,  -------87 

Of  Congenital  Narrowness  of  the  Vagina,  - - - - - 94 

Of  Accidental  Obliteration  and  Stricture  of  the  Vagina,  ...  100 

Of  Obturation  of  the  Vagina  and  the  Means  of  cure,  - - - - 106 

Surgical  Treatment  of  Accidental  Cohesion  of  the  Vaginal  Parietes;  and  of 

Congenital  Obturation  of  the  Vagina,  - - - - - 111 

Occlusion  of  the  Cervix  Uteri,  - - - - - - -113 

Atresia  of  the  Fallopian  Tubes,  - - - - - -115 

Of  Absence  of  the  Vagina — and  of  Cases  in  which  the  Vagina  opens  into  the 

Rectum  or  Bladder,  - - - - - - - 116 

Absence  of  the  Womb  and  Means  by  which  it  can  be  ascertained,  - - 118 


SECOND  SECTION. 

CHAPTER  VI. 


Lesions  of  Situation,  - ------  - 121 

Of  Hysteroptosis,  - - - - - - - -122 

Of  Pessaries  and  their  Varieties,  - - - - - - 133 

Of  the  principal  Pessaries  in  use,  and  the  Method  of  Employing  them,  - 139 

Of  the  choice  of  a Pessary,  - - - - - - -145 

Accidents  connected  with  the  presence  of  a Pessary  in  the  Vagina,  - - 145 

Complications  contra-indicating  the  use  of  the  Pessary,  and  Indications  in 

certain  peculiar  cases,  - 149 

Cure  of  Prolapsus  Uteri,  -------  150 

Extirpation  of  the  Prolapsed  Womb,  ------  152 

Method  of  Operating,  - - - - - ...  -152 

Of  Anteversion  and  Retroversion  of  the  Womb,  - - - - 154 

Of  the  Anteflexion  and  Retroflexion  or  Curvature  of  the  Uterus,  - - 169 

Of  Inclination,  and  Obliquity  of  the  Womb,  - 172 

Of  Inversion  of  the  Womb,  - - - - . . -175 

Of  Elevation  of  the  Womb,  - - - - . . -190 

Of  Abnormal  Immobility  of  the  Womb,  -----  191 

Of  Hysterocele  or  Hernia  of  the  Womb,  - - - - - 194 

Inguinal  Hysterocele,  --------  195 

Crural  Hysterocele,  - - - . - . - - 195 


CONTENTS.  Xlll 

Ventral  Hysterocele,  - - - - - - - -196 

Hernia  of  the  Ovary,  - 198 

Vaginal  Cystocele,  or  Hernia  of  the  Bladder  in  the  Vagina,  - - - 201 

Prolapsion  of  the  Mucous  Membrane  of  the  Urethra,  - 204 

Vaginal  Enterocele,  - 205 

Vulvar  Enterocele  and  Cystocele,  - - - - - 208 

Of  Inversion  and  Swelling  of  the  Lining  Membrane  of  the  Vagina,  - - 209 

Invagination  of  the  Vagina,  -------  214 


THIRD  SECTION. 

CHAPTER  VII. 


Physical  Lesions,  - --  --  --  - 215 

Contusion  of  the  Labia  Majora,  - - - - - - 216 

Of  Rupture  of  the  Perineum  and  the  Means  of  remedying  it,  - - - 217 

Of  Lacerations  and  of  Rupture  of  the  Vagina,  ....  224 

Of  Contusions  and  Wounds  of  the  Uterus,  -----  227 

Contusions  and  Wounds  of  the  Mammae,  -----  229 

Of  Rupture  of  the  Uterus,  -------  230 

Of  Vaginal  Fistulas,  - --  --  --  - 238 

Of  Vesico-Vaginal  and  Recto-Vaginal  Fistulas,  - - - - 238 

Of  the  Palliative  Method,  -------  243 

Temporary  Palliative  Method,  -------  244 

Of  Tamponnement,  and  of  Dessault’s  Method,  ...  - 245 

Of  Cauterization,  --------  246 

Of  the  Suture, 249 

Method  of  the  Author,  -------  - 252 

Of  the  Approximation  of  the  Edges  of  Vagino-Vesical  Fistulas  by  means  of 

peculiar  instruments,  without  the  use  of  the  Suture,  - - - 257 

Of  Recto-Vaginal  Fistulas,  - - - - - - -261 

A Recto-Vaginal  Fistula,  cured  by  J.  Rhea  Barton,  M.D.,  - - - 264 

Of  Foreign  Bodies  accidentally  introduced  into  the  Vagina,  the  Uterus  and 

the  Canal  of  the  Urethra,  ------  266 


FOURTH  SECTION. 

CHAPTER  VIII. 


Vital  and  Organic  Lesions,  -------  268 

Superficial  Inflammation  of  the  Vulva,  -----  269  ^ 

Of  Prurigo  of  the  Vulva,  -------  269 

Of  Phlegmon  and  deep-seated  Inflammation  of  the  Labia  Majora,  - - 272 

Gangrenous  Inflammation  of  the  Labia  Majora,  - - - 273 

Acute  Inflammation  of  the  Vagina,  ------  274 

Inflammation  of  the  Parenchyma  and  Lining  Membrane  of  the  Uterus,  - 276 

Treatment  of  Acute  Metritis,  -------  284 

Of  Chronic  Metritis  or  Subacute  Inflammation  of  the  Proper  Tissue  of  the 

Uterus,  - - - - - - - - - 293 

Chronic  Metritis  without  Engorgement,  -----  294 


XIV 


CONTENTS. 


Chronic  Metritis  with  Engorgement,  ------  295 

Engorgement  of  the  Uterus  without  Induration,  ...  - 297 

Of  CEdema  of  the  Neck  of  the  Uterus,  -----  299 

Sanguine  Engorgement  of  the  Uterus  with  or  without  Haemorrhage,  - - 300 

Congestive  Engorgement  with  Haemorrhage,  -----  301 

Of  Primary  Engorgement  with  Induration,  -----  303 

Of  Scirrhous  Engorgement,  -------  304 

Tubercular  Induration,  - 305 

Of  Leucorrhoea,  or  the  Whites,  ------  307 

Of  Redness,  Simple  Ulcerations,  and  Eruptions  upon  the  Os  Tincae,  - - 323 

Of  Chancres,  and  Scrofulous  Ulcers,  etc.,  upon  the  Os  Tincae,  - - 325 

Of  Carcinomatous  Ulcers,  -------  327 

Of  Cancer  of  the  Uterus,  -------  328 

Treatment  of  Cancer  of  the  Womb,  ------  338 

Surgical  Treatment  of  Cancer,  ......  344 

Amputation  of  the  Neck  of  the  Uterus,  -----  346 

Modifications  of  the  Operation  by  the  Author,  ...  - 349 

Of  Hysterotomy  performed  without  displacing  the  Uterus,  - - - 351 

Description  of  the  Operation,  -------  352 

Advantages  of  the  Author’s  Method,  ------  356 

After-Treatment,  - 358 

Extirpation  of  the  Cancerous  Uterus,  ------  360 

Physometra,  or  Tympanitis  of  the  Womb,  -----  366 

Of  Hydrometra,  or  Dropsy  of  the  Womb,  -----  374 

Of  Hydatids  of  the  Womb,  - - - - - - £ - 373 

Of  Calculi  of  the  Womb,  and  other  Genital  Parts,  ...  - 381 

Of  Polypus  of  the  Womb  and  Vagina,  -----  385 

Inflammation  of  the  Ovaria  and  Fallopian  Tubes,  - - - - 410 

Of  Dropsy  of  the  Ovaries,  and  Fallopian  Tubes,  ...  - 420 

Of  Cancer  of  the  Ovarium  and  other  Degenerations  of  that  organ,  - - 433 

Cancer  of  the  Vagina  and  external  Organs  of  Generation,  - - - 437 

Of  CEdema,  Varix,  and  other  Tumours  of  the  Vulva,  - - - - 438 

Cancer  of  the  Breast,  - - - - - - - -441 

Of  Encysted  Tumours,  and  different  kinds  of  Chronic  Engorgement  of  the 

Mammae,  --------  457 


FIFTH  SECTION. 


CHAPTER  IX. 

Lesions  of  the  Functions,  ------  459 

Of  Amenorrhoea,  - --  --  --  - 463 

'Of  Dysmenorrhcea,  --------  479 

Of  Immoderate  Flow  of  the  Menses  and  other  Uterine  Haemorrhages,  - 483 

Of  Metrorrhagia,  - - - - - - ...  486 

Of  Chlorosis  or  Green  Sickness,  ------  495 

Of  Nymphomania,  or  Furor  Uterinus,  ------  513 

Of  Hysteria  and  other  Spasmodic  Diseases  of  Women,  ...  518 

Hysteriform  Attacks,  - - - - - - - 536 

Of  Gastro-Intestinal  Spasm,  -------  538 

Of  Hysteralgia,  --------  540 


CONTENTS. 


XV 


CHAPTER  X. 


Special  Hygiene  of  Women,  - 542 

Hygienic  Rules  concerning  Puberty  and  Menstruation,  - - - 552 

Hygienic  Rules  in  relation  to  the  Union  of  the  Sexes,  ...  546 

Hygienic  Rules  relative  to  the  Change  of  Life,  - • - 549 

General  Hygiene  of  Women,  -------  552 


SIXTH  SECTION. 

CHAPTER  XI. 


Lesions  relative  to  Reproduction,  ------  562 

Of  Impotence  and  Sterility,  -------  562 

Of  False  Pregnancy,  --------  568 

Of  Moles,  or  Depraved  Conception,  ------  570 

Of  Extra-Uterine  Pregnancy,  -------  574 

Of  Gastrotomy,  ---------  583 

Of  Diseases  connected  with  Pregnancy,  -----  584 

Of  Abortion  or  Miscarriage,  -------  585 

Of  Nausea  and  Vomiting,  -------  595 

Of  Ptyalism,  - --  --  --  --  597 

Of  Odontalgia,  --------  - 598 

Of  Anorexia,  --------  - 599 

Of  Boulimia,  - --  --  --  --  599 

Of  Dyspepsia  and  Polydipsia,  -------  600 

Of  Capricious  Appetite,  (Pica,  Malacia,)  -----  600 

Of  Pyrosis,  Dysphagia  and  Heartburn,  - - - - - 601 

Of  Gastralgia,  ---------  602 

Of  Enteralgia,  --------  - 604 

Of  Constipation,  - --  --  --  - 604 

Of  Diarrhoea,  Dysentery  and  Tenesmus,  -----  605 

Of  Dyspnoea,  --------  - 606 

Of  Cough, 609 

Of  Haemorrhages  occurring  during  Pregnancy,  - 610 

Of  Haemoptysis,  Haernatemesis  and  Epistaxis,  - - - 616 

Disorders  of  the  Circulation  during  Pregnancy,  - - - 61 S 

Of  Palpitation,  - - - - - - - - - 619 

Of  Syncope,  ---------  621 

Of  Varices,  - --  --  --  --  622 

Of  Haemorrhoids,  --------  624 

Of  (Edema,  - - - - - - - - 625 

Of  Cephalalgia  and  Vertigo,  627 

Insomnia,  or  Agrypnia,  --------  628 

Lesions  of  the  Sight,  the  Hearing,  the  Smell,  &c.,  - 629 

Disorders  of  the  Intelligence  and  of  the  Moral  Inclinations  and  Affections,  - 631 

Of  Eclampsia,  or  Puerperal  Convulsions,  -----  632 

Disposition  to  Fall,  - 646 

Disorders  of  the  Urinary  Organs  during  Gestation,  ...  - 647 

Pains  in  different  parts  during  Pregnancy,  -----  648 


XVI 


CONTENTS. 


Diseases  connected  with  the  Lying-in,  - 
After-Pains,  - 

Accidents  relative  to  the  Lochia,  - 
Of  Milk-Fever,  ------ 

Of  Puerperal  Peritonitis,  - 

Of  Uterine  Phlebitis,  - - - - - 

Of  other  kinds  of  Puerperal  Phlebitis, 

Of  Painful  (Edema,  - - - - 

Puerperal  Neuritis,  - 

Of  Phlegmonous  Abscess  in  Lying-in  Women, 

Inertia  of  the  Womb,  and  Flooding  depending  thereon, 

Of  Miliary  Eruption,  - - - - - 

Lesions  relative  to  Lactation,  - 

Polygalactia,  and  Milk-Consumption,  - 

Diseases  of  the  Mammae,  - 

Of  Inflammation  of  the  Mammae,  or  the  Weed, 

Hygiene  of  Pregnant  and  Lying-In  Women, 

List  of  Authors,  - 
Ihdex, 


649 

649 

651 

652 

654 

661 

665 

682 

684 

684 

685 

687 

688 

689 

692 

693 

696 

705 

715 


A 


TREATISE 

OX  THE 

DISEASES  OF  FEMALES. 


CHAPTER  I. 

HISTORY  OF  THE  PHYSICAL,  MORAL  AND  PHYSIOLOGICAL  CHANGES  WHICH  TAKE  PLACE  IX 
FEMALES  AT  THE  PRINCIPAL  EPOCHS  OF  LIFE* 

Feeble  and  sensitive  at  birth,  and  destined  by  nature  to  give  us 
existence  and  to  preserve  us  afterwards  by  means  of  her  tender  and 
watchful  care,  woman,  the  most  faithful  companion  of  man,  may  be 
regarded  as  the  very  complement  of  the  benefits  bestowed  upon  us 
by  the  Divine  Being ; as  an  object  fitted  to  excite  our  highest  inte- 
rest, and  presenting  to  the  philosopher,  as  well  as  to  the  physician,  a 
vast  field  of  contemplation. 

What  subject,  indeed,  is  more  worthy  of  our  attentive  meditation 
than  the  ‘series  of  changes,  physical,  moral  and  physiological,  that 
accompany  every  stage  of  woman’s  existence ! By  a long  succes- 
sion of  modifications  and  revolutions,  she  discloses  all  the  phases  of 
her  constitution.  In  infancy  she  differs  slightly  from  the  male,  in 
whose  pleasures  and  amusements  she  participates,  as  well  as  in  his 
dispositions  and  tastes,  his  inconstancy  and  vivacity.  At  that  early 
period,  ignorant  of  her  own  sex,  ignorant,  so  to  speak,  of  her  own 
nature,  the  blush  of  modesty  does  not  mantle  on  her  cheek,  and  her 
eyes,  which  reveal  no  passions,  seem  to  seek  only  what  has  reference 
to  her  real  wants. 

Although  at  this  early  epoch  her  body  is  but  a sketch  of  the  forms 
it  is  destined  to  assume  at  a later  period,  she  always  retains,  even 
after  her  entire  development,  some  touch  of  the  softness  and  delicacy 
peculiar  to  childhood,  and  does  not  depart  so  widely  as  her  playmate 
from  the  idea  of  her  original  constitution. 

The  reproductive  faculty  divides  the  life  of  the  female  into  three 
very  distinct  periods  or  stages.  In  the  first,  this  property  has  no 
existence*,  in  the  second  it  is  in  fpll  activity,  and  in  the  third  it  has 
become  null  again.  The  duration  of  the  first  commonly  decides  that 
2 


IS 


PHENOMENA  OF  PUBERTY. 


of  the  two  last  periods;  so  as  to  establish  the  general  rule  that  the 
old  age  of  woman  comes  earlier  in  proportion  as  her  puberty  has 
been  more  precocious. 

The  vital  forces  that  regulate  the  organic  system,  and  the  organs  that 
constitute  that  system,  gradually  increase  during  the  first  period  of 
life;  they  attain  their  perfect  development  in  the  second ; and  diminish 
and  become  extinct  at  the  close  of  the  third,  whose  term,  like  that  of 
the  others,  may  be  accelerated  or  retarded  by  different  accidental 
causes  and  circumstances,  dependent  on  certain  physical  and  moral 
conditions. 

Upon  setting  out  in  the  career  of  life,  the  two  sexes  exhibit  nearly 
the  same  physiognomical  characters  and  the  same  delicacy  of  organi- 
zation. Their  type  and  their  character,  as  yet  indeterminate,  differ 
only  by  almost  imperceptible  modifications,  and  which  it  is  not  pos- 
sible to  trace  out  in  full  detail.  Subject  to  the  same  functions  and 
wants,  their  isolated  and  individual  existence  fails,  as  yet,  to  reveal 
the  sympathetic  relations  that  are  in  the  end  destined  to  establish 
between  them  a state  of  reciprocal  dependence.  Subjects  of  the 
same  kinds  of  diseases,  they  are  principally  liable  to  the  convulsive 
affections,  and  especially  to  inflammation  of  the  brain,  because  the 
head,  which,  in  infancy,  has  a proportional  size  greater  than  in  any 
other  age,  is,  in  them  a vital  centre,  towards  which  almost  all  the 
efforts  of  the  organisms  are  directed. 

The  shades  of  difference  in  the  sexes  soon  assume  a more  de- 
cided tone;  and  their  peculiar  characters  become  so  much  the  more 
marked  as  the  development  of  each  individual  is  more  complete  and 
approaches  more  nearly  to  the  period  when,  by  a sudden  change, 
nature  reveals  the  completion  of  those  preparations  she  has  been 
silently  making. 

The  interval  betwixt  the  tenth  year  and  the  age  of  puberty  is  a 
period  of  transition,  a sort  of  passage  from  childhood  to  adolescence, 
which  appears  to  be  the  happiest  era  in  the  life  of  the  female.  Her 
extreme  nervous  mobility  prevents  her  being  too  long  impressed  by 
the  grave  sentiments  that  might  be  fitted  to  interfere  with  her  happi- 
ness. This  being  for  young  women  the  period  of  gentle  pleasures  and 
of  the  freest  gaiety,  it  follows  that  imagination  exhibits  every  object 
under  the  most  attractive  colours,  and  that  the  existence  of  young 
females  is  agreeably  varied  by  a piquant  freedom  of  action  and  a 
great  mobility  of  tastes  and  affections.  Exempt,  at  this  age,  from 
cares  and  troubles,  they  sing,  they  weep  and  laugh  at  the  same  mo- 
ment; and,  as  their  joys,  so  their  pleasures  and  their  grief,  as  well  as 
all  their  other  impressions,  are  ephemeral;  they  proceed  along  a 
flowery  path  up  to  the  age  when  nature  calls  on  them  for  the  tribute 
which  they  owe  to  the  species. 

The  young  girl  who,  until  now,  was  an  equivocal,  non-sexual  crea- 
ture, becomes  a woman  in  her  countenance  and  in  all  the  parts  of 
her  body,  in  the  elegance  of  her  stature  and  beauty  of  her  form,  the 
delicacy  of  her  features,  in  her  constitution,  in  the  sonorous  and 
melodious  tones  of  her  voice,  in  her  sensibility  and  affections,  in  her 
character,  her  inclinations,  her  tastes,  her  habits  and  even  in  her 


PHENOMENA  OF  PUBERTY. 


19 


maladies.  Very  soon  are  all  the  traits  of  resemblance  between  the 
two  sexes  found  to  be  effaced.  The  bud  newly  expanded  blossoms 
amongst  the  flowers,  and  this  brilliant  metamorphosis  is  signalized 
by  the  rosy  tints  of  the  cheeks  and  lips,  and  the  perfect  development 
which  discloses  the  arrival  of  the  age  of  puberty. 

This  important  period,  this  first  moment  of  triumph  in  which  nature 
seems  to  renew  herself,  is  announced  by  a sentiment  of  necessity  to 
multiply,  within,  the  principle  of  life,  and  by  various  striking  and 
admirable  phenomena  which  put  an  end  to  the  social  inertia  in  which 
the  young  girl  had  lived  from  the  period  of  her  birth.  The  sexual 
organs  soon  become  a centre  of  fluxion;  nature  makes  great  efforts 
in  order  to  establish  the  periodical  discharge,  and  the  whole  machine 
experiences,  in  its  inmost  recesses,  a succussion,  a violent  commotion, 
a general  movement.  The  new  energy  of  the  womb  impresses  a 
powerful  impulse  upon  the  entire  system  of  organs;  their  functions 
become  more  active;  the  body  grows  with  rapidity;  the  various 
portions  of  the  figure  become  more  expressed,  and  bring  out  those 
graceful  contours  which  belong  to  the  tender  sex  alone.  At  the  same 
time  other  important  changes  take  place ; the  pelvis  and  the  sexual 
organs,  which  were  in  a rudimental  condition  only,  now  acquire  their 
full  proportions ; the  throat  rises  and  becomes  more  sensitive ; the 
breasts  become  rounded  and  full,  while  they  establish  their  corre- 
spondence of  sympathy  with  the  womb.  The  mons  veneris  comes 
out  into  complete  relief,  and  clothes  itself  with  a thick  down,  which, 
like  a veil  covering  the  organs  of  modesty,  seems  to  announce  that 
they  are  destined  soon  to  become  fitted  to  act  the  important  part 
assigned  to  them  by  the  law  of  nature.  The  meshes  of  the  cellular 
[and  adipose]  tissue,  becoming  rapidly  dilated  under  the  influence 
of  the  uterine  irradiations,  soon  impart  to  the  surface  of  the  body 
a voluptuous  embonpoint  which  lends  the  highest  splendour  to  the 
attractive  beauty  and  freshness  of  youth. 

The  physiognomy  of  the  young  woman  has  now  acquired  a new 
expression;  her  gestures  bear  the  stamp  of  her  feelings;  her  language 
has  become  more  touching  and  pathetic ; her  eyes,  full  of  life  but 
languishing,  announce  a mixture  of  desires  and  fears,  of  modesty 
and  love — in  fine,  every  thing  conspires  to  excite,  to  caress  and  to 
incite. 

Her  tastes,  her  enjoyments  and  her  inclinations  are  modified  like 
the  rest ; her  most  pressing  want  is  to  experience  frivolous  emotions ; 
she  is  passionately  given  to  the  dance,  shows  and  company;  the 
curiosity  so  natural  to  her  sex  acquires  new  force  and  activity;  she 
devours  books  of  romance,  or  more  than  ever  fervent  in  devotion, 
is  excited  by  the  expansive  passions,  and  particularly  by  religious 
piety,  which  is  to  her  a sort  of  love. 

At  this  brilliant  period  of  life  her  moral,  which  depends  upon 
her  physical  condition,  undergoes  great  mutations.  The  young  girl 
becomes  more  tender-hearted,  more  sensitive,  more  compassionate, 
and  appears  to  attach  herself  to  every  thing  about  her.  The  new 
sensations  of  her  soul  make  her  timid  in  approaching  the  compa- 
nions of  her  childhood;  a strange  trouble,  a sort  of  restlessness,  an 


20 


PHENOMENA  OF  PUBERTY. 


agitation  before  unknown,  are  the  heralds  of  a power  whose  exist- 
ence she  does  not  even  suspect. 

The  action  of  the  new  forces  of  vitality  established  within  the 
sexual  organs  augments  more  and  more,  and  reacts  with  energy 
upon  the  whole  system.  Under  the  sympathetic  irradiations  of  the 
uterus  the  general  sensibility  becomes  changed  and  even  excited  in 
a peculiar  manner.  A new  sentiment  soon  gives  rise  to  desires 
which,  as  yet,  have  no  definite  object,  and  to  vague  emotions,  of 
an  instinct  that  seeks  some  object — it  knows  not  what.  This  rising 
want  produces  the  impression  of  a touching  melancholy,  a charming 
bashfulness,  whose  principle  is  founded  in  ingenuous  love,  presaging 
new  dispositions  and  announcing  that  the  inclinations  and  habits  of 
childhood  are  exchanged  for  other  sentiments.  The  young  virgin 
becomes  timid,  reserved,  abstract  and  dreamy.  She  sighs  less  for 
pleasure  than  for  happiness ; the  necessity  of  loving  makes  her  seek 
solitude — and  this  new  want,  that  troubles  her  heart  and  engages 
it  wholly,  becomes,  if  it  remain  unsatisfied,  a source  of  multiplied 
disorders  and  derangements. 

Various  causes  calculated  to  render  the  play  of  the  vital  forces 
more  active,  have  the  effect  either  of  retarding  or  precipitating  the 
age  of  puberty : thus,  abundant.  and  stimulating  food  and  drinks,  man- 
ners, habits  and  climate,  exercise  a marked  influence  upon  this  vital 
phenomenon.  Certain  moral  circumstances  may  likewise  accelerate 
its  arrival ; but  the  artificial  maturity  thus  resulting  always  acts  inju- 
riously upon  the  organization:  among  these  circumstances  may  be 
enumerated  premature  passions  and  pleasures,  the  arts  of  imitation, 
music,  painting,  the  perusal  of  obscene  romances,  the  inspection  of 
lascivious  pictures,  the  theatre  and  the  ball-room ; the  bad  examples 
and  the  premature  libertinism,  of  which  too  many  samples  are  unfor- 
tunately furnished  in  great  cities.  These  specimens  of  premature 
puberty,  the  miserable  consequence  of  too  great  vivacity  of  the  ima- 
gination, are  sometimes  met  with  as  early  as  the  eighth  or  tenth  year. 

The  normal  puberty  that  is  announced  by  the  eruption  of  the 
menses,  is,  in  our  climate,  not  generally  observed  before  the  fifteenth 
or  sixteenth  year;  but  its  period  is  different  according  to  the  region 
in  which  the  subject  lives.  In  southern  countries,  for  example,  as  in 
Greece,  Italy  and  Spain,  under  the  beautiful  skies  of  Provence  or 
Languedoc,  young  girls  are  often  found  to  be  grown  vp  at  twelve 
or  sixteen  years  of  age  ; and  in  certain  Asiatic  countries,  heated  by 
a burning  sun,  the  young  women  become  marriageable  as  early  as 
the  tenth  or  eleventh  year.  In  the  cold  latitudes,  on  the  contrary,  as 
in  Sweden,  Norway  or  Lapland,  it  is  not  uncommon  for  the  women 
to  be  as  late  as  the  twentieth  or  twenty-fifth  year  before  the  erup- 
tion of  the  menses,  or  even  still  later. 

in  general,  the  crisis  of  puberty  is  more  distressing  for  females  than 
for  males,  especially  for  such  as  are  endowed  with  a very  delicate 
and  nervous  constitution,  as  often  happens  to  such  as  lead  a seden- 
tary life,  and  have,  acquired  the  habits  and  manners  appertaining  to 
the  opulent  and  luxurious  classes. 

The  most  important  physiological  phenomenon  of  this  era  con- 


PHENOMENA  OF  PUBERTY. 


21 


sists  in  the  eruption  of  the  catamenia,  which  depends  upon  the  new 
mode  of  vitality  established  in  the  sexual  organs.  When  nothing: 
has  occurred  to  interrupt  the  operation  of  the  laws  of  the  economy, 
the  uterus,  which  in  the  little  girl  was  quiescent  and  unaroused, 
acquires  a considerable  degree  of  activity,  together  with  an  exalted 
state  of  sensibility.  The  full-grown  woman  very  soon  becomes  the 
subject  of  the  mensual  revolution,  which  terminates  in  a real  crisis, 
and  by  a haemorrhage  from  the  womb  more  or  less  considerable, 
according  to  circumstances. 

[There  are  very  conflicting  statements  as  to  the  influence  of  climate  on 
puberty.  In  order  to  have  a reliable  authority,  I addressed  a note  to  Dr. 
Joseph  Maria  Vargas,  of  Caraccas,  in  Venezuela,  requesting  information 
from  him  on  the  subject  of  puberty,  and  the  change  of  life  in  that  climate. 
Dr.  Vargas  is  the  same  gentleman  who,  some  years  since,  was  President  of 
the  Republic  of  Venezuela,  and  is  well  known  for  his  devotion  to  every 
thing  relative  to  philosophical  pursuits:  he  is  the  author  of  a system  of 
surgery  in  two  volumes,  published  at  Caraccas  in  1842,  and  is  professor  in 
that  university.  In  his  answer  to  my  note,  under  date  of  May  2d,  1844, 
he  says:  “As  to  the  points  you  are  desirous  of  ascertaining,  regarding  the 
epoch  of  puberty  and  the  critical  age  of  the  women  of  this  country,  you  will 
find  adjoined  my  answer,  (to  your  queries,)  embodying  the  information  of 
the  most  practical  physicians  of  this  city,”  and  he  gives  the  following 
table : — 

First. — Common  epoch  of  puberty. 

In  70  per  cent,  menstruation  from  13  to  15 
“ 10  “ “ “ “11  to  12 

in  very  rare  cases  at  10 
“ 20  “ “ “ “ 16  to  18 

very  rare  cases  19  to  20 
and  even  21 

Second. — Critical  age  common  from  45  to  48 

In  a few  cases  40  to  44 

In  a few  cases  49  to  50 

In  very  rare  cases  38  to  40 
In  very  rare  cases  51  to  53 

Dr.  Vargas  informs  me  that  precocious  menstruation  is  more  common  in 
the  white  than  in  the  negro  race. 

In  Lee’s  Lectures  on  Midwifery , p.  44,  is  a statement  of  the  epoch  at 
Antigua,  where  Dr.  Nicholson  never  met  with  it  before  the  fourteenth  year. 
Dr.  Lee  doubts  whether  intertropical  women  menstruate  earlier  than  others. 
The  reader  is  referred  to  Lee’s  Fourth  Lecture  for  a statement  of  the  con- 
flicting reports  upon  the  influence  of  climate  in  precipitating  or  procrasti- 
nating the  eruption  of  the  catamenia,  and  also  to  Raciborski. 

The  period  of  eruption  in  1781  women  of  England  and  France,  which  I 


22 


PHENOMENA  OF  MENSTRUATION. 


have  calculated  from  the  tables  of  Brierre  de  Boismont  (Z?e  la  Menstruation , 
&c.,  Paris,  1842,  p.  39,)  and  Lee’s  Lecture,  was  as  follows: — 


At 

11 

years 

in 

110 

At  16 

“ “ 284 

t( 

12 

44 

44 

144 

“ 18 

44  44  144 

44 

13 

44 

44 

256 

• ♦ 

“ 19 

44  4 4 72 

44 

14 

44 

44 

360 

“ 20 

“ “ 40—: 

44 

15 

.44 

44 

366 

PHENOMENA  OF  MENSTRUATION. 

Menstruation  is  a distinctive  characteristic  of  the  human  species, 
for,  except  at  the  coupling  season,  no  other  animal  is  subject  to  a 
periodical  discharge  from  the  sexual  organ. 

In  some  females  the  first  eruption  of  the  menses  takes  place  sud- 
denly, and  without  the  least  premonitory  sign.  The  blood,  by 
accumulating  within  the  organ  destined  at  some  future  period  to 
contain  the  embryo,  by  its  superabundant  quantity,  opens  an  easy 
way  of  escape  by  a before  unaccustomed  route. 

[I  do  not  perceive  the  necessity  or  force  of  this  remark,  if  he  refers  to 
the  cavity,  since  it  is  certain  that  a drop  of  fluid,  whether  of  blood  or  any 
other  liquor,  can  never  have  the  least  difficulty  in  escaping  from  the  cavity 
of  the  fundus  and  body  of  the  womb,  along  the  canal  of  the  cervix,  which 
is  always  sufficiently  open  to  admit  of  the  introduction  of  a medium  bougie, 
even  to  the  fundus  uteri. — M.] 

In  the  major  part  of  the  cases,  however,  the  first  mensual  haemor- 
rhage  is  both  preceded  and  accompanied  by  various  inconvenient 
circumstances.  A real  febrile  movement  is  set  up  ; the  pulse  is  full, 
irregular,  bounding ; a considerable  heat  is  felt  in  the  genitalia, 
which  become  tumid,  painful  and  sensitive,  occurrences  which  are 
also  observable  with  regard  to  the  mammary  glands.  The  young 
girl  complains  of  general  plethora,  cephalalgia,  suffocation,  colic  and 
other  symptoms,  the  signs  of  uterine  congestion,  such  as  pain  in  the 
loins,  with  a sense  of  weight  in  the  thighs  and  in  the  pubic  region. 
In  some  cases  spasmodic  cough  is  noticed,  and  the  sleep  is  disturbed 
by  palpitations  and  wearisome  dreams.  At  this  period,  the  young 
adolescent  becomes  sad  and  melancholy,  and  gives  herself  up  to 
indulgence  in  reverie,  the  cause  of  which  she  does  not  understand  ; 
she  is  now  more  susceptible,  impressionable,  and  becomes  subject  to 
violent  emotion  from  very  slight  causes.  She  grows  more  irascible, 
often  has  queer  appetites,  and  is  ‘Capricious — her  imagination  is 
more  elevated,  and  a secret  instinct  gives  her  the  presentiment  of 
that  important  destiny  that  nature  calls  her  to  fulfil. 

At  length  the  flow  makes  its  appearance,  preceded  and  followed 
by  a muco-serous  discharge ; it  is  in  inconsiderable  quantity,  rarely 
lasts  more  than  two  or  three  days,  and  at  first  recurs  at  irregular 
periods,  but  acquires  precision  after  the  fourth  or  fifth  return. 


PHENOMENA  OF  MENSTRUATION. 


23 


[There  are  a great  many  persons  to  be  met  with  who  become  regular  at 
first,  and  who  continue  so  throughout  the  whole  period  of  the  menstrual 
life.— M.] 

In  women,  already  regular,  the  discharge  is  gentle  or  moderate, 
but  without  any  interruption  from  beginning  to  end.  On  the  first 
day  it  is  scarcely  a show , but  increases  progressively  until  the  third  ; 
from  which  time  it  gradually  lessens  until  the  fifth  or  sixth,  more  or 
less.  By  this  time  great  relief  is  obtained,  all  the  precursory  symp- 
toms have  vanished,  and  nothing  remains  but  a feeling  of  languor, 
which  makes  her  seek  repose,  not  exercise — the  countenance  has  a 
languishing  look,  the  cheeks  are  pale,  the  eyes  are  less  bright,  and 
have  a dark  palpebral  areola,  the  breasts  continue  to  be  painful,  the 
odour  of  the  breath  and  perspiration  is  strong,  and  there  is  in  the 
genital  parts  a sense  of  heat,  and  pruritus  which  provoke  the  aphro- 
disiac sense. 

[M.  Colombat  has,  in  the  above  paragraph,  painted,  in  colours,  perhaps,  a 
little  too  strong,  the  features  of  a healthful  menstruation.  I am  assured,  by 
many  persons  in  the  various  classes  of  society,  that  the  menstrual  act  is,  in 
them  at  least,  unattended  by  such  very  marked  signs  of  constitutional  con- 
sent as  M.  C.  would  seem  to  believe.  Many  of  them  have  assured  me, 
during  more  than  thirty  years,  that  for  them  the  catamenia  have  never  been 
the  occasion  of  the  least  trouble  or  the  smallest  modification  of  their  health. 
The  flow  begins,  continues  and  ends  without  sensation  or  inconvenience, 
except  what  arises  from  the  needful  cares  as  to  cleanliness  of  the  person.  I 
am  very  much  inclined  to  think,  seeing  that  so  many  millions  of  women 
exist  who  never  make  the  least  complaint  of  their  menstruae,  it  is  only  in 
particular  cases  that  the  reader  should  adopt  M.  Colombat’s  description,  and 
not  in  all  cases. — M.] 

There  are  women  who,  though  always  very  regular,  are  quite  ill 
at  each  menstrual  revolution — such  persons  are  generally  unwell 
and  suffering  at  the  approach  of  the  menses,  and  some  of  them 
suffer  from  various  accidental  affections,  as  colic,  headache,  vapours, 
spasms,  hysterics,  convulsions,  and  even  epilepsy.  In  others  the 
digestive  functions  become  deranged  and  painful.  The  patient  feels 
debilitated,  and  the  memory  is  weakened : all  women  at  this  time 
readily  take  cold,  are  soon  fatigued,  and  as  they  are  generally  more 
sensitive  to  all  sorts  of  impressions,  they  become  more  susceptible, 
sad,  timid,  irascible,  and  subject  to  caprices  that  claim  not  indul- 
gence only,  but  the  tenderest  commiseration. 

The  relief  that  follows  the  menstrual  travail  is  a sure  index  of  the 
regularity  of  this  function,  which  in  general  recurs,  when  well  esta- 
blished, at  fixed  periods  of  twenty-eight  or  thirty  days,  and  in  this 
regard,  in  some  females,  seems  to  correspond  with  the  phases  of  the 
moon.  This  opinion,  being  generally  entertained  among  the  vulgar, 
has  been  reduced  to  a proverb  by  the  poet: — 

“Luna  vetus  vetulas,  juvenes  nova  luna  repurgat.” 


24 


PHENOMENA  OF  MENSTRUATION. 


Instead  of  having  any  reference  to  the  lunar  month,  Haller  and 
some  other  authors  suppose  rather  that  the  menses  coincide  with  the 
solar  months.  Gail,  whilst  not  admitting  a sidereal  influence,  be- 
lieves that  the  discharge  will  be  found  generally  to  take  place  at 
about  the  same  period  of  time,  and  that  there  are  certain  weeks  in 
each  month  in  which  no  women  are  menstruating.  He  divides  the 
menstrual  epochs  into  two  classes — comprising  the  first  eight  days  of 
the  first  and  second  fortnights,  that  is  to  say,  the  first  and  third  weeks: 
if  there  be  women  who,  from  accidental  causes,  become  unwell  dur- 
ing the  second  and  fourth  weeks,  he  pretends  that,  after  some  months, 
they  will  return  under  obedience  to  the  general  law;  but  Dr.  Gall 
furnishes  no  explanation  of  the  cause  of  her  general  menstruation 
at  two  different  epochs.  Many  women  are  met  with  who,  in  all 
other  respects,  are  in  fine  health,  yet  in  whom  the  periodical  re- 
turns anticipate  as  regards  the  lunar  months.  Thus  certain  nervous 
women,  especially  such  as  are  of  an  erotic  temperament,  are  found 
to  menstruate  every  fortnight,  while  others,  of  an  opposite  constitu- 
tion, are  subject  to  the  returns  only  every  six  weeks,  or  even  only 
every  two  months.  Linnaeus  says  that  he  saw  women  in  Lapland 
whose  discharges  occurred  only  once  a year.  In  his  Treatise  on 
Diseases  of  the  Womb,  Dr.  Pauly  relates  that  M.  Lisfranc  has  met 
with  women  who  were  regular  every  fifth  or  sixth  month,  or  only 
every  fourth  and  even  sixth  year.  Some  of  these  women  were 
habitually  disordered,  and  others  enjoyed  perfect  health — in  the  first 
case  the  indications  would  be  the  same  as  for  persons  who  had 
never  yet  menstruated ; hut  we  shall  return  to  this  subject  in  treating 
of  the  diseases  of  menstruation. 

[I  see  no  propriety  in  citing  such  cases  as  these  as  samples  of  menstrua- 
tion. I should,  in  all  such  instances,  be  inclined  to  regard  the  flow  as  a 
malady  merely,  and  not  as  the  result  of  the  regular  exercise  of  a normal 
physiological  function.  A lady,  for  example,  informed  me  yesterday, 
(March  14,  1844,)  that  she  was  regular  at  thirteen,  and,  after  giving  birth 
to  twelve  children,  lost  her  catamenia  definitively  at  35  aetat.;  after  having 
seen  nothing  for  seven  years,  she  had  a very  copious  menstruation.  She 
has  had  uninterrupted  health  all  her  life  long.  I could  not  regard  the  case 
in  question  otherwise  than  as  an  incident  in  her  history  having  probably  no 
relation  to  the  menstrual  function.  The  case  mentioned  by  M.  Colombat 
below,  is,  however,  of  a different  character. — M.] 

The  Duchess  of  D.,  celebrated  as  much  for  her  wit  as  for  her  ad- 
mirable literary  talents,  assured  me  that,  having  ceased  to  menstruate 
at  thirty-five,  she  supposed  she  had  reached  her  critical  age ; the 
more  especially  as  she  became  marriageable  at  an  early  age ; but  at 
about  her  forty-fifth  year,  that  is  to  say,  after  ten  years  of  menstrual 
suppression,  she  again  became  regular.  From  that  time  the  duchess, 
who  is  at  present  fifty-three  years  of  age,  has  been  as  regular  as  she 
was  in  her  youth. 

The  menstrual  revolution  has  been  attributed  to  a variety  of  causes. 
Aristotle,  Mead,  Werlhoff,  Vanhelmont,  Roussel  and  some  other 


PHENOMENA  OF  MENSTRUATION. 


25 


authors  supposed  it  to  depend  upon  lunar  influence;  Pliny  thought 
it  was  the  excretion  of  a noxious  substance;  Galen,  Astruc,  Simpson 
and  Lobstein  could  perceive  in  it  nothing  more  than  the  expulsion  of 
a superfluous  quantity  of  blood.  Frederick  Hoffmann  supposed  the 
menstrual  flux  to  be  the  fruit  of  a mechanical  action.  He  says  that 
women  generate  more  blood  than  they  need,  in  consequence  of  the 
slowness  of  their  circulation  and  the  small  amount  of  their  perspira- 
tion. Hence  arise  venous  congestions  and  spasms  in  the  extreme 
vessels.  The  blood  that  is  refused  admittance  into  the  vessels  that 
are  affected  with  spasmodic  constriction  must  escape  into  the  womb, 
whose  particular  structure  favours  this  congestion.  M.  Osiander  and 
some  other  German  physicians  allow  that  menstruation  takes  place 
on  account  of  the  excess  of  carbon  and  azote  contained  in  the  blood 
of  the  womb.  Paracelsus,  Silvius  and  De  Graff  regarded  it  as  the 
product  of  a fermentative  principle.  Clifton  avers  that  it  depends 
upon  the  weakness  of  the  venous  paries,  as  related  to  the  perpendi- 
cular effort  of  the  fluid.  Emett  regarded  it  as  consequent  upon  a 
state  of  erection  ; Lecat  as  an  amorous  phlogosis;  Stahl  and  Professor 
Luges  think  that  it  takes  place  under  an  irr  it  ament  um,  a peculiar 
molimen ; and,  lastly,  the  position  of  the  uterus  and  certain  arrange- 
ments of  its  blood-vessels  have  been  assigned  as  the  causes  of  the 
menstrual  discharge. 

[I  feel  compelled,  by  a sense  of  duty  to  the  reader,  to  make  some  remarks 
upon  the  causes  of  menstruation  additional  to  those  cited  by  M.  Colombat, 
and  which,  to  the  merest  tyro,  must  appear  unsatisfactory.  It  seems  to  be 
universally  admitted  that  the  substantial  causes  of  menstruation  ought  to 
be  sought  for  in  a condition  of  the  female  ovaries,  which  are  regarded  as 
the  proper  seats  of  the  reproductive  faculty,  not  only  as  being  the  points  in 
which  the  aphrodisiac  faculty  most  essentially  dwells,  but  as  influencing  the 
female  constitution  in  the  remarkable  manner  known  to  be  coincident  with  the 
development  of  those  bodies  and  also  consequent  upon  the  abstraction  of  their 
vital  energies  after  the  lapse  of  years.  In  the  male  the  full  unfolding  of  the 
size,  form  and  power  of  the  testes  is  the  sign  and  guarantee  of  the  repro- 
ductive force,  and  the  same  is  true  of  the  ovary  of  the  female,  in  whom,  up 
to  the  age  of  puberty,  these  organs  are  known  to  be  incomplete. 

The  total  absence,  by  congenital  deformity  or  by  ablation  or  by  diseased 
destruction,  of  both  ovaries,  is  known  to  be  attended  with  loss  of  the  men- 
strual power,  as  well  as  of  the  erotic  principle.  The  atrophy  of  the  same 
organs,  by  the  progress  of  age,  equally  involves  the  abolition  of  the  men- 
strual force.  If  these  propositions  be  true,  it  follows  that  the  seat  of  the  men- 
strual force  must  be  conceded  to  exist  in  the  ovaries.  But  the  question  as  to 
how  that  force  comes  to  be  exerted  upon  the  constitution  in  a manner  so  sur- 
prising, in  the  regular,  equable  and  necessary  exercise  of  it,  was  unexplained 
until  the  simultaneous  development  of  the  new  theory  of  menstruation  by 
MM.  Negrier  and  Gendrin  in  France,  and  Lee  in  England.  This  is  not  the 
place  to  settle,  even  were  it  in  my  power,  the  claims  of  the  rivals  for  the 


26 


PHENOMENA  OF  MENSTRUATION. 


honour  of  originating  this  new  philosophy.  The  reader  who  takes  interest 
in  that  point  is  referred  to  M.  Negrier’s  reclamation  against  M.  Gendrin,  in 
his  Recherches  Anat.  et  Physiolog.  sur  les  Ovaires , Paris,  1840,  8vo.;  and 
to  Lee’s  Midwifery , and  Raciborski’s  late  work,  Be  la  Puberte , &c.  M. 
N.,  in  the  preface,  shows  that  so  early  as  November,  1831,  he  read  a paper 
upon  the  theory  at  the  Medical  Society  of  Angers,  and  also  made  it  known, 
after  considerable  researches,  at  Paris,  in  1838,  to  Messrs.  P.  Dubois,  Berard, 
sen.,  Cullerier,  jun.,  and  Ollivier  d’Angers.  But,  unfortunately  for  him, 
M.  Gendrin  gave  a very  lucid  statement  of  the  theory  and  of  the  facts  which 
illustrate  and  uphold  it,  in  his  Traite  Philos,  de  Med.  Pratique,  1838.  Dr. 
Robert  Lee,  of  London,  whose  rising  fame  seems  destined  to  eclipse  all  his 
English  brethren,  also  had  perceived  the  truths  of  nature  upon  this  point  as 
early  as  1831.  T.  L.  G.  Bischoff,  in  his  Entwickelungsgeschicte  der 
Saugthierre  und  des  Menschen , Leipzig,  1842,  and  which  has  been  trans- 
lated by  M.  Jourdan  and  published  in  the  Encyclopedic  Anatomique,  1843, 
speaks  of  this  new  doctrine  as  follows:  “At  first  I opposed  this  doctrine, 
for  it  seemed  to  me  improbable  that,  after  so  many  researches  and  discus- 
sions on  the  subject  of  the  corpora  lutea,  it  had  not  been  long  since  examined ; 
and  because,  had  it  been  true,  there  must  have  been  found  corpora  lutea  in 
the  numerous  subjects  dying  during  the  menstrual  act  and  examined  by  the 
anatomists.  However,  I have  since  had  opportunities  of  examining  the 
bodies  of  two  women  who  died  while  menstruating,  and  in  both  of  them  I 
not  only  found  the  ovaries  very  turgid  and  gorged  with  blood,  but  I also 
discovered  a well-marked  Graafian  vesicle,  open,  and  containing  a corpus 
luteum  in  the  process  of  its  development.  I have  also  become  satisfied  that, 
if  the  sexual  union  is  prevented,  with  animals  in  heat,  the  swollen  follicles 
are  likewise  converted  into  a sort  of  corpora  lutea.  Lastly,  since  the  period 
referred  to,  I have  carefully  examined  all  the  ovaries  I have  met  with  of 
persons  dying  in  puberty:  there  is  always  to  be  found  a tuberculated  and 
cicatrized  surface,  and,  at  least  in  many  of  them,  traces  of  imperfect  corpora 
lutea,  even  where  there  had  been  no  antecedent  conception.  I look  upon  it 
as  an  indubitable  fact,  that  this  appearance  is  the  result  of  antecedent  men- 
struation,” &c. 

The  most  finished  and  complete  account  of  the  matter,  however,  is  that 
which  is  contained  in  M.  Negrier’s  work  above  mentioned,  and  in  Raci- 
borski,  op.  cit.  M.  N.’s  is  a full-sized  octavo  of  131  pages,  with  eleven 
lithographic  plates,  which  present  fifty-three  figures,  representing  the  ova- 
ries and  womb  in  different  circumstances.  He  divides  his  work  into  three 
parts.  In  Part  I.,  which  is  divided  into  four  chapters,  he  commences,  Chap- 
ter I.  with  an  anatomical  account  of  the  ovaries,  exhibiting  their  structure  at 
the  different  periods  of  life,  from  birth  to  puberty.  The  second  chapter 
exposes  the  state  of  the  ovaries  during  the  reproductive  life  of  the  woman. 
Chapter  III.  concerns  the  anatomy  of  the  ovaries  during  gestation  and  lacta- 


PHENOMENA  OF  MENSTRUATION. 


27 


tion.  Chapter  IV.  is  assigned  to  the  exposition  of  their  condition  in  wo- 
men who  have  finally  ceased  to  menstruate. 

In  Part  II.  M.  N.  advances  certain  physiological  considerations  and  de- 
ductions from  the  facts  previously  cited, — while  the  third  and  last  part  is 
devoted  to  points  relative  to  the  physiological  and  pathological  anatomy  of 
the  organs  in  question. 

The  result  of  his  researches  in  Part  I.  is  given  in  a resume , at  p.  12, 
as  follows.  The  parenchyma  ( stroma ) of  the  ovary  of  a new-born  child  is 
homogeneous.  In  the  first  year  it  is  found  to  contain  an  uncertain  number 
of  miliary  granulations,  as  large  as  poppy  seeds,  each  of  which  is  surrounded 
by  a whitish  zone.  At  the  third  year  and  forwards  to  the  sixth,  the  ovaries 
increase  in  size,  but  undergo  no  change  of  shape.  A small  globule,  con- 
taining a drop  of  serous  fluid,  is  found  glued  to  one  of  the  granules,  whose 
white  zone  has  sensibly  diminished  in  size.  These  globules,  which  are 
rarely  larger  than  a millet  seed,  have  pretty  thick  walls,  but  they  may  be 
easily  crushed  between  the  fingers.  The  globule  or  lodge  contains  a vesicle 
comprised  in  two  concentric  membranes  that  are  contiguous.  At  about  the 
tenth  year  some  of  the  globules  enlarge,  but  a grayish  pulpy  matter  is  depo- 
sited betwixt  the  outer  and  inner  concentric  membranes,  so  that  the  vesicle 
that  is  innermost  is  compressed  and  becomes  wrinkled.  These  vesicles  M. 
Negrier  denominates  ( bourses  grises ) gray  pouches.  The  gray  pulp  of  the 
pouches  gradually  changes  to  a yellowish  colour,  and  it  is  then  the  first 
signs  of  puberty  become  manifest  in  the  girl.  In  infancy  and  childhood  the 
vesicles  are  found  nearest  the  adherent  margin  of  the  ovary,  after  which  they 
are  found  to  be  nearer  to  the  free  margin  of  the  organ,  and  when  they  begin 
to  form  gray  pouches,  they  are  in  contact  with  the  indusium  of  the  gland,  but 
there  is  no  sign  of  cicatrices  upon  the  surface  of  the  ovarium.  During  this 
entire  period  the  womb  has  remained,  so  to  speak,  stationary,  and  its  muta- 
tions of  size  have  no  comparison  with  those  that  take  place  in  the  before- 
mentioned  body. 

In  Chapter  II.  M.  Negrier  shows  that,  whenever  an  opportunity  has  been 
enjoyed  of  examining  the  condition  of  the  ovaries  in  women  who  have  died 
suddenly  while  menstruating,  there  has  been  always  observed  a point  on  the 
ovarian  surface  which  appears  to  have  been  ruptured  or  lacerated.  In  such 
as  have  died  a long  time  after  the  cessation  or  suspension  of  the  menses,  no 
trace  of  recent  rupture  could  be  found. 

Dr.  Gendrin  gives,  at  p.  18,  vol.  ii.,  his  first  case,  which  occurred  in 
1828;  and  Dr.  Robert  Lee  ( London  Medical  Gazette , 1842-3,  p.  165, 
vide  also  Lee’s  Theory  and  Practice  of  Midwifery , p.  47,  Phila.,  1844), 
relates  a case  that  he  observed  on  the  11th  of  March,  1831,  with  others  , 
subsequently. 

The  frequent,  if  not  invariable,  occurrence  of  a rupture  of  the  Graafian 
vesicle,  coincidently  with  the  menstrual  act,  may  be  taken,  one  would  think, 
as  tenable  grounds  for  the  belief  that  this  development  and  rupture  are  suffi- 


28 


PHENOMENA  OF  MENSTRUATION. 


cient  causes  of  the  phenomena  presented  by  that  great  and  most  important 
sexual  function.  The  discovery  of  the  vesicle  of  the  bird’s  egg,  by  Pur- 
kinje,  and  the  elucidation  of  the  nature  of  the  human  ovum,  by  Baer 
Coste,  Wharton  Jones,  Barry  and  others,  throw  new  light  upon  this  topic. 
It  is  fully  understood  that  De  Graaf’s  vesicle  is  but  the  organ,  the  ovisac, 
which  contains  the  egg  of  the  mammal,  a microscopic  point,  consisting  of  a 
yolk  with  its  germinal  vesicle  and  germinal  spot,  which  is  kept  steady  in 
the  centre  or  moved  to  the  surface  of  the  cyst  or  cell  in  which  it  exists,  by 
a granular  membrane,  like  the  chalaze  of  the  hen’s  egg,  and  which  has 
received  from  M.  Barry  the  name  of  retinacula,  the  existence  of  which  is 
denied  by  Bischoff. 

Barry  has  shown,  and  any  one  who  possesses  a good  microscope  can 
observe  for  himself,  that  the  ovary  contains  an  immense  number  of  granules, 
which  are  the  nuclei,  or  nucleoli,  of  the  germinal  cell.  They  amount  to 
unknown  numbers,  millions,  perhaps,  and  are  of  exceeding  minuteness  ; but, 
in  passing  from  the  state  of  nucleus  to  that  of  ovisac,  they  cannot  fail  to  com- 
press the  ovarian  stroma,  and  dispart  its  cellular  tela,  its  vessels  and  nerves; 
in  like  manner  as  the  sac  which  incloses  the  rudimental  tooth,  presses  aside 
and  disparts  the  structure  of  the  gum  in  a young  child,  producing  upon  its 
constitution  various  effects,  from  the  very  slightest  manifest  uneasiness  to 
the  most  fatal  spasm,  convulsion,  cholera,  <fcc.  &c. 

But  it  is  universally  admitted  that  the  human  female,  unlike  the  other 
mammals,  has  no  stated  season  of  reproductiveness;  that  she  is  liable  to 
fecundation  at  any  period  of  her  reproductive  age.  Hence  it  appears  clearly 
that  a necessity  exists  for  her  evolving  and  perfecting  the  germina  of  her 
offspring,  throughout  the  entire  series  of  years  from  puberty  until  the  arrival 
of  her  critical  age.  Supposing  her  to  be  perfectly  regular,  and  never  to  be- 
come pregnant,  she  would,  in  the  course  of  thirty  years,  have  nearly  four 
hundred  menstruations.  If,  now,  each  menstruation  is  to  be  taken  as  the 
sign  of  her  constitutional  aptitude  for  fecundation,  it  is  a just  inference  that 
such  aptitude  must  bear  a close  relation  to  the  perfectness  of  the  germ-cell 
or  ovulum  of  the  Graafian  vesicle.  Let  it  be  admitted,  then,  that  a vesicle 
is  always  found  to  have  been  discharged  in  the  cases  of  women  dying  sud- 
denly in  the  menstrual  act,  and  it  does  not  seem  to  be  a violent  wresting  of 
the  facts  to  apply  them  to  the  solution  of  this  great  problem,  the  cause  of 
menstruation.  MM.  Gendrin,  Negrier,  Lee,  Raciborski  and  Bischoff  alf 
concur  in  the  statement  that  in  menstruation  the  ovarian  vesicle  is  burst, 
with  loss  of  the  ovula  and  granules  or  retinacula — that  the  ovarian  stroma 
and  indusium  are  highly  injected  and  vascular — that  a similar  condition 
exists  in  the  tube  and  womb,  and  thus  is  sufficiently  established  a hyperce- 
mic  status  of  the  internal  genitals,  to  account  for  the  entire  local  plethora  or 
uterine  hyperffimia,  whose  result  is  the  menstrual  discharge.  Here,  at  last, 
we  see  established  the  doctrine  of  a local  plethora  as  a cause  of  menstrua- 
tion, and  that  plethora  resting  on  a sure  physiological  basis — the  regular 
periodical  development,  to  wit,  of  the  Graafian  vesicle  with  its  contents. 


PHENOMENA  OF  MENSTRUATION. 


29 


The  question  as  to  why  it  should  have  so  exact  a periodical  character,  is 
no  more  difficult  of  solution  than  that  of  the  stated  periods  of  eruption  of  the 
first  and  second  dentition,  the  growth  and  fall  of  the  hair  or  the  beard,  &c., 
or  the  periodical  affections  of  the  sphincters  under  a regularly  operating  law 
in  physiology. 

In  adopting  the  'dews  of  the  writers  whose  names  have  been  so  re- 
peatedly mentioned,  I find  abundant  explanations  of  the  poverty  of  our 
resources  in  the  use  of  the  mere  menagoga,  and  in  the  efficacy  of  the  treat- 
ment of  menstrual  disorders,  by  a regard  fixed  upon  the  constitution,  whose 
disorders  are  fully  sufficient  to  impair  the  ovarian  travail,  by  suspending  the 
development  of  the  vesides,  under  disease  of  other  organs,  or  of  the  repro- 
ductive system  itself,  or  by  precipitating  and  rendering  dangerous  an  irrita- 
mentum  whose  gentle  and  aormal  influences  ought  to  produce  no  pain  nor 
be  attended  by  the  least  interruption. 

Dr.  M.  A.  Raciborski,  of  Paris,  has  put  forth,  in  the  present  year,  1844,  a 
small  volume  already  mentioned,  upon  the  subject  of  menstruation,  of  the  very 
highest  interest.  It  is  entitled  De  la  Puberte  et  de  V Jige  Critique  chcz  la  Fem- 
me, au  point  de  Vue  Physiologique,  Hygienique  et  Medicate , et  de  la  Ponte 
Periodique  chez  la  Femme  et  les  Mammiferes.  M.  R.  shows  that  the  deve- 
lopment of  the  Graafian  vesicle  ought  to  be  considered  not  merely  as  the  cause 
of  menstruation,  hut  as  menstruation  itself;  and  that  a woman  may  regularly 
develop  her  ova  and  be  liable  to  conceive  even  when  she  may  have  never  had 
the  outward  and  visible  signs  of  the  catamenia.  After  having  related  certain 
cases  of  very  late  occurrence  of  the  catamenia,  he  says,  at  p.  89:  “ These 
facts  seem  only  to  confirm  what  we  shall,  in  a subsequent  page,  fully  esta- 
blish, to  wit,  that  the  menstrual  haemorrhage  is  but  a secondary  phenomenon 
in  menstruation,  properly  so  called,  and  that  the  capital  phenomenon  in  this 
function  consists  in  the  maturation  and  the  periodical  discharge  of  the  ova 
or  the  ‘ ponte, ’ (laying.)  There  are  women  in  whom  it  is  confined  to  this 
act  alone,  and  we  have  the  records  of  cases  in  which  women  have  given 
birth  to  several  children  without  having  ever  seen  the  menses.” 

Such  is  the  short  statement  I have  thought  proper  to  add  to  M.  Colombat’s 
views  of  the  causes  of  menstruation.  But  I should  gladly  refer  the  reader 
to  Negrier,  to  Gendrin,  to  Robert  Lee  and  Raciborski. — M.] 

The  immortal  Bichat,  in  his  Anatom.  Gen.,  says  that  the  blood 
that  flows  in  a menstruation  is  of  the  same  nature  with  that  which 
escapes  in  any  other  active  hasmorrhage.  It  proceeds  principally 
from  the  womb  and  escapes  from  the  capillaries  on  the  mucous  sur- 
face, where,  incited  by  a lively  irritation,  it  is  conducted  into  unac- 
customed channels  and  expelled  by  a process  of  exhalation. 

In  his  anatomical  researches  upon  the  position  of  the  glands  and 
their  action,  Theoph.  de  Bordeu  gives  out  nearly  the  same  opinion. 
“The  womb  and  the  vagina  effect  an  excretion  of  blood  almost  as  pure 
in  common  as  that  which  flows  in  the  vessels.  This  excretion  comes 
every  month  or  nearly  so;  it  begins  about  the  age  of  twelve  or  fifteen 
years  and  terminates  towards  the  fortieth  or  fiftieth,  and  is  generally 


30 


PHENOMENA  OF  MENSTRUATION. 


suspended  during  suckling  and  under  certain  diseases  ffiat  occasion 
discharges,  whether  sanguine  or  of  other  character,  &c.  The  excre- 
tion of  the  womb  takes  place  as  it  does  in  all  the  other  glands — that 
we  have  denominated  active  glands.  The  organ  awakes , ( erigitur ,) 
and,  by  the  turns  ( replis ) which  it  makes  upon  itself,  it  invites  the 
blood  and  rejects  it  outwards  by  the  same  mechanism  we  have  else- 
where explained.  Each  organ  acting  in  its  turn,  that  of  the  womb 
recurs  only  from  month  to  month.  Why?  This  is  what  we  are 
ignorant  of— and  what  we  seek  to  know.” 

In  women  the  menses  may  be  regarded  as  the  aurora  and  com- 
panions of  puberty.  In  fact,  though  there  be  samples  wherein  a 
sanguine  discharge  from  the  vulva  may  have  been  noticed  in  children 
of  from  two  to  six  years  old,  or  in  women  who  have  attained  to  an 
advanced  age,  true  menstruation  does  not  commence  until  the  period 
when  the  young  girl  is  fitted  to  become  a mother — and  ceases  when 
she  loses,  together  with  her  charms,  the  faculty  of  conceiving  in  the 
womb.*  This  moment  of  sexual  dissolution  generally  arrives  about 
the  fortieth  or  fiftieth  year,  earlier  or  later. 

Menstruation,  then,  is  a physiological  function  which  characterizes 
the  period  during  which  the  female  is  endowed  with  the  reproductive 
faculty.  From  the  first  appearance  of  the  menses  until  the  term  when 
they  are  to  cease  by  the  lapse  of  years,  her  health,  her  freshness  and 
her  beauty  depend  upon  the  regular  return  of  this  sanguine  evacua- 
tion.! Those  who  experience  no  menstrual  revolution  are  rarely 
fruitful,  and  its  sudden  suppression  in  youth  and  in  health  is  one  of 
the  least  deceptive  signs  of  conception. 

When  the  periodical  evacuation  meets  with  obstacles,  and  nature 
makes  vain  efforts  to  establisu  it,  all  the  powers  of  life  diminish  or 
become  perverted;  and  trouble  and  disorder  among  the  functions 
throw  a speedy  veil  over  the  brilliancy  of  the  maiden.  A crowd  of 
symptoms  often  comes  to  aggravate  this  dull  languor,  the  respiration 
becomes  difficult,  the  circu/ation  languishes,  the  tastes  and  appetite 
are  perverted,  depraved,  the  feet  and  limbs  begin  to  swell,  the  eye- 
lids to  be  tumid,  the  face  is  bloated,  and  acquires  a sallow  hue,  or  a 
greenish  or  chalky  tint : at  length  painful  palpitations,  frequent  faint- 

* Professor  Osiander,  of  Goettingen,  has  noted  that  of  137  women,  9 were  regular 
at  12  aetat.,  8 at  13,  21  at  14,  32  at  15,  24  at  16,  11  at  17,  18  at  18,  10  at  19,  8 at  20, 
and  1 at  21,  and  one  other  at  24.  From  this  statistical  view  of  menstruation  it  is 
seen  that  the  mean  age  for  the  apparition  is  between  fifteen  and  sixteen  years. 

f We  know  a lady  thirty  years  of  age  who  has  never  been  regulated,  and  who, 
nevertheless,  enjoys  perfect  health.  She  has  had  no  children,  notwithstanding  that 
she  has  been,  since  her  eighteenth  year,  united  to  a husband  who  is  young  and  in 
vigorous  health.  The  sister  of  this  lady  is  also  married  and  has  never  been  regulated ; 
but  she  has  had  one  child — a healthy  one.  The  annals  of  the  science  furnish  many 
similar  examples.  Rondellet,  chancellor  of  the  faculty  at  Montpellier,  speaks  of  a 
woman  who  had  twelve  children,  and  Joubert,  his  pupil  and  successor,  speaks  of  one 
who  gave  birth  to  eighteen  children,  though  neither  of  these  women  had  menstruated. 
Zacchias  and  Fodere  have  also  related  similar  observations.  We  may  add  that  the 
periodical  discharge  furnishes,  in  its  history,  numerous  examples  of  anomalies  and 
deviations;  but  all  these  irregularities  and  menstrual  aberrations  do  not  impair  the 
validity  of  the  general  rule,  for,  being  the  fruits  of  some  disorder  of  the  womb,  they 

constitute  real  cases  of  disease.  [Madame  N 1 informed  me  tfiat  she  had  given 

birth  to  ten  children,  and  that  she  had  never  menstruated  since  her  marriage,  having 
always  become  pregnant  before  the  return  of  her  courses  after  a confinement. — M.j 


PHENOMENA  OF  MENSTRUATION.  31 

ings,  a deep-felt  anxiety,  distress,  weakness  of  the  senses,  a certain 
indolency,  and  a weariness  which  renders  every  motion  disagreeable 
— come  to  obscure  this  sad  and  afflicting  picture. 

During  the  entire  period  of  the  menstrual  life,  women  are  exposed 
to  the  attack  of  a great  variety  of  maladies,  to  most  of  which  they 
are  not  liable  antecedently  to  the  age  of  puberty ; for  they  draw 
their  sources  from  irregular  menstruation,  or  from  the  sympathetic 
reaction  of  the  womb.  Among  the  disorders  of  this  class,  without 
comprising  such  as  are  connected  with  pregnancy,  we  must  cite  the 
cases  of  hysteria,  catalepsy,  convulsions,  spasmodic  diseases,  cardi- 
algia,  dyspnoea,  chlorosis  and  leucorrhoea ; to  which  may  be  added 
consumption,  and  various  forms  of  haemorrhage,  as  epistaxis,  haemo- 
ptoe,  haematemesis,  and  a variety  of  febrile  affections  unnecessary  to 
detail  in  this  place. 

The  nature  and  properties  of  the  blood  of  the  menses  have  been, 
from  the  remotest  antiquity,  the  object  of  a crowd  of  popular  preju- 
dices and  scientific  errors,  the  absurdity  of  which  can  hardly  be  con- 
ceived of.  According  to  Aristotle,  this  kind  of  blood  is  as  pure  as 
that  which  flows  from  any  wound.  Hippocrates  compares  it  with 
that  of  a slaughtered  victim.  Sanguis  autem....sicut  ct  victimd,  si 
sana  fuerit  mulier.  Pliny,  in  speaking  of  the  menstrual  fluid,  says, 
* on  the  other  hand,  that  it  is  a fatal  poison,  that  it  corrupts  and  decom- 
poses urine,  deprives  seeds  of  their  fecundity,  destroys  insects,  that  it 
blasts  the  garden  flowers  and  grasses,  and  causes  fruits  to  fall  from 
their  branches,  &c.  Nihil  facile  reperiatur  mulierum  profluvio  magis 
monstrificum.  Acescunt  superventu  musta,  sterilescunt  tactse  fruges, 
moriuntur  insita,  exuruntur  hortorum  germina,  et  fructus  arborum, 
quibus  insedere  decidunt.  (Lib.  vii.  cap.  15.) 

The  Lawgiver  of  the  Hebrews  goes  still  further  when  he  says, 
“And  if  a man  shall  lie  with  a woman  having  her  sickness,  and  shall 
uncover  her  nakedness,  he  hath  discovered  her  fountain,  and  she  hath 
uncovered  the  fountain  of  her  blood,  and  both  of  them  shall  be  cut 
off  from  among  their  people.”  (Lev.  xx.  18.) 

A number  of  authors,  and  amongst  others,  Columella,  [Dr  Re  rus- 
tica ,)  whose  eloquence  and  style  savour  so  strongly  of  the  Augustan 
age,  Graaf,  [Mul.  Org.  Gener.,)  Verheyen,  ( Vera  Hislor.  de  Horrend. 
Sang.,)  the  Arabians,  and  even  some  among  the  modern  writers, 
have  attributed  dangerous  qualities  to  the  blood  of  the  menstruae. 
In  perusing  the  histories  of  various  nations,  whether  savage  or  civil- 
ized, we  find  that  most  of  them  have  entertained  the  same  preju- 
dices, and  have  established  customs  no  less  barbarous  than  injurious 
to  the  female.  At  a crisis  in  which  they  ought  to  be  the  objects  of 
the  highest  interest,  instead  of  finding  protection  and  security,  they 
have  been  compelled  to  sequester  themselves  from  society,  and  sub- 
mit to  the  most  humiliating  precautions.*  It  appears,  says  Roussel, 

* M.  Moreau  de  la  Sarthe,  in  the  Hist.  Nat.  de  la  Femme,  Tom.  II.  261,  also  says 
that  the  Negroes,  the  South  Sea  Islanders,  and  the  Aborigines  of  South  America, 
send  their  females  into  separate  huts,  and  keep  them  in  a state  of  absolute  seques- 
tration during  the  whole  menstrual  period.  The  Illinois  Indians  punish  with  death 
their  women  who  fail  to  give  notice  of  their  being  affected  with  their  periodical  flux. 
History  also  informs  us  that  by  a decree  of  the  Council  of  Nice,  women  were  forbid- 
den to  enter  the  church  while  menstruating. 


32 


PHENOMENA  OF  MENSTRUATION. 


( Systhne  Physique  et  Moral  de  la  Femme,)  that  the  male  feeling  him- 
self more  at  liberty  during  this  transitory  crisis,  in  which  the  charms 
of  the  female  are  somewhat  obscured  by  a slight  shade,  would  profit 
by  the  interregnum  thus  left  to  him,  in  order  to  revolt  and  outrage 
her,  whom,  in  all  other  circumstances,  he  is  compelled  to  adore. 

The  opinion  of  Hippocrates  as  to  the  identity  of  the  menstrual  and 
other  haemorrhages,  finds  few  opponents  at  the  present  day,  and 
although  there  are  still,  especially  among  the  common  people,  some 
prejudices  as  to  the  pernicious  qualities  of  the  menstrual  fluid,  the 
major  part  of  the  medical  profession,  at  the  present  time,  look  upon 
the  discharge  as  being  equally  pure  with  the  blood  of  other  sanguine 
effusions.  Any  differences  as  to  its  nature  or  smell  are  attributable 
to  the  changes  it  undergoes  in  the  vagina.  Such  a decomposition  of 
the  menses  may  communicate  properties  of  a more  or  less  dele- 
terious nature,  and  cause  it  to  react  upon  certain  fluids  easy  of 
decomposition.  It  is  very  desirable  that  researches  more  careful,  and 
conducted  without  prejudice,  might  serve  to  throw  light  upon  this 
long-vexed  question,  and  dispel  those  injurious  opinions  in  regard  to 
a sex  whose  condition  and  well-being  ought  to  be  a constant  care. 

The  quantity  of  blood  that  escapes  at  each  period  varies  accord- 
ing to  climate.  Hippocrates  thought  that  the  Greek  women  lost 
twenty  ounces  or  two  cotyla  at  each  menstruation.  Galen  estimated 
it  at  eighteen  ounces.  Haller  computed  it  at  six,  eight  or  twelve 
ounces  for  the  German  women.  According  to  Dehaen,  it  amounts 
to  three  ounces  in  England, but  Smellie  and  Dobson  suppose  it  to  be 
four  ounces.  Pasta  says  it  is  five  ounces,  and  Freind  ten  ounces. 
Gorter  thinks  that  in  Holland  the  discharge  does  not  exceed  six. 
Fitzgerald  estimates  it  at  fourteen  or  fifteen  ounces  for  Spanish 
women.  Astruc  says  that  it  varies  from  eight  to  ten  ounces  among 
the  French  women ; and  Baudelocque  regards  it  as  amounting  only 
to  three  or  four.  Lastly,  M.  Magendie  thinks  it  is  often  very  great 
and  may  amount  to  several  pounds. 

Linnaeus  avers,  in  his  Flora  Lapponica,  that  the  women  of  frozen 
regions,  as  the  Samoiedes,  lose  but  a very  small  quantity  of  blood, 
and  that  only  in  the  summer  season;  and  that  the  Greenlanders 
have  scarcely  any  discharge,  on  account  of  the  cold,  which  hinders 
the  development  of  the  generative  faculties  as  it  does  the  flower- 
ing of  plants.  From  the  foregoing,  then,  it  is  perceived  that,  as 
a general  rule,  the  catamenia  are  most  abundant  in  those  coun- 
tries where  puberty  is  most  early  attained.  But  on  this  point  there 
will  be  found  considerable  differences,  according  to  the  different  con- 
stitutions of  women  ; thus,  the  Greeks  of  the  Archipelago,  who  are 
more  precocious  than  the  Italians,  and  inhabit  a warmer  climate, 
rarely  lose  more  than  three  ounces  of  blood.  It  is  quite  certain  that 
European  women,  who  migrate  to  a hotter  climate,  as  the  West  and 
East  Indies,  to  live  particularly  at  Batavia  or  in  Java,  often  perish 
in  consequence  of  excessive  menstrual  losses,  and  are,  besides,  more 
liable  to  abortions  than  under  more  temperate  skies. 

The  difficulty  of  collecting  the  menstrual  blood,  and  the  numerous 
variations  in  the  amount  of  the  discharge,  have  necessarily  occasioned 


PHENOMENA  OF  MENSTRUATION. 


33 


the  differences  of  reports  by  the  observers  whose  names  we  have 
now  cited.  All  calculations  upon  this  subject  must  be  more  or  less 
faulty,  and  we  can,  therefore,  only  expect  approximative  results  in 
our  various  estimates. 

[I  maybe  permitted  to  remark  here,  that  seeing  that  all  women  in  health, 
and  not  pregnant  nor  suckling,  ought  to  menstruate  regularly,  and  that  they 
vary  in  constitution  as  much  as  in  intellectual  and  moral  character  or  pro- 
pensity, we  ought  not  to  expect  to  ascertain  a standard  quantity  as  the 
rule  of  the  sex.  What  the  female  requires  as  such,  is  to  menstruate,  and 
not  to  discharge  just  so  many  ounces,  more  or  less.  Indeed,  that  which  is 
sufficient  to  maintain  the  health  of  a woman  in  one  period  of  her  life,  or  in 
one  state  of  society,  might  be  either  too  little  or  too  much  for  her  constitu- 
tion under  changed  circumstances  of  age  or  social  relations.  Each  woman 
is  a law  unto  herself,  and  provided  she  obey  that  law,  she  is  well,  if  not, 
by  excess  or  deficiency,  by  anticipation  or  procrastination,  she  falls  sick. 
It  is  well  known,  that  in  a great  metropolis  like  Paris  or  Philadelphia,  there 
exist  multitudes  of  women  who  do  not  take  the  least  precaution  to  prevent 
the  blood  of  the  menses  from  soaking  through  their  clothes,  and  exposing 
their  condition  to  the  public  eye,  in  the  street  or  in  the  marketplace.  I have 
met  with  many  healthy  women  who  informed  me  they  never  put  on  the 
napkin,  and  I doubt  not  that  we  daily  meet  with  hundreds  of  menstruating 
women  who  wear  no  cloth  for  the  purpose  of  receiving  the  discharge. 
Nevertheless,  it  is  an  event  of  the  most  extreme  rarity  to  find  a spot  of  blood 
upon  the  stocking  or  dress  of  a woman  : in  such  persons  it  is  not  possible 
to  conceive  that  the  loss  amounts  to  more  than  three  or  four  ounces.  But 
in  a great  many  others  the  quantity  is  enormous.  For  example,  when  I 
have  desired  to  obtain  information  on  this  point  from  my  patients,  I have 
inquired  as  to  the  number  of  changes  used  in  the  whole  period  of  five  or 
seven  days,  and  I have  been  repeatedly  informed  that  they  change  twice  or 
thrice,  and  some  even  four  times  in  twenty-four  hours.  Now  three  changes 
per  diem  for  seven  days,  will  give  twenty-one  napkins,  on  each  of  which  is 
found  at  least  two  tablespoonfuls  of  blood,  or  more  ; but  with  the  estimate  of 
two  spoonfuls  to  each,  we  shall  have  the  result  of  twenty-one  ounces  for 
the  whole  product.  I am  confident  that  many  healthy  women  lose  fully 
this  quantity  as  the  regular  and  normal  elimination.  M.  Brierre  de  Bois- 
mont,  in  his  work  De  la  Menstruation , p.  172,  says,  in  speaking  of  the 
analysis  of  the  fluid,  “This  task  has  lately  been  taken  up  by  M.  Bouchar- 
dat,  who  had  the  goodness  to  analyze  the  blood  of  one  of  my  patients,  who 
submitted  to  experiments  for  this  purpose — one  of  the  most  disagreeable  and 
distressing  that  could  be  thought  of.  In  order  to  collect  a quantity  amount- 
ing to  twenty-two  grammes,  about  one  ounce,  it  was  necessary  that  a specu- 
lum, embracing  the  cervix  uteri  exactly,  should  be  retained  in  situ  for  ten 
consecutive  hours,”  <fcc.  Now,  if  this  woman  yielded  an  ounce  in  ten 
hours,  she  would  give  more  than  two  ounces  in  twenty-four  hours ; bift  at 
3 


34 


PHENOMENA  OF  MENSTRUATION. 


the  same  rate  for  seven  days,  the  sum  of  the  discharge,  it  is  seen,  would  be 
not  far  from  fifteen  or  sixteen  ounces.  I repeat  my  opinion,  that  what  it 
interests  us  as  medical  counsel  to  know  is,  not  what  is  the  usual  quantity 
for  women,  but  what  is  the  rate  of  the  particular  woman  in  her  ordinary 
health:  her  deviations  from  her  own  economic  law  are  the  signs  and  mea- 
sures of  her  disorder. — M.] 

Unwilling  to  extend  our  observations  further  upon  a topic  treated 
perhaps  too  much  in  extenso  already,  I shall  abstain  from  repeating 
all  that  has  by  authors  been  stated  in  regard  to  the  menses  and  their 
periodicity.  The  opinions  of  the  writers  who  have  treated  this  point 
are  so  different  and  often  so  contradictory,  that  we  shall  content  our- 
selves with  adding  that  the  mechanism  of  the  function  is  always  the 
same,  whether  the  discharge  takes  place  within  the  body  or  the 
cervix  uteri,  in  the  vagina  or  in  the  appendages.  Most  modern 
physiologists  regard  the  menstrual  evacuation  as  an  active  haemor- 
rhage, and  the  effect  of  a peculiar  excitement  of  the  womb,  but  have 
not  as  yet  settled  the  point  as  to  whether  the  discharge  takes  place 
from  the  arteries  of  the  capillary  system  or  from  vessels  of  the  venous 
system. 

The  mystery  of  menstruation  will  be  for  ever  covered  with  a veil 
which  cannot  be  perfectly  removed.  Under  this  conviction,  we  shall 
confine  ourselves  to  the  statement  that  the  flow  takes  place  when- 
ever, under  the  influence  of  a special  law  of  the  organization,  the 
womb  acquires  a certain  intensity  of  vital  force  proper  to  attract  the 
blood  towards  itself  at  the  periodical  epochs. 

We  shall  also  add  that  the  cause  of  the  regular  intermittence  of 
this  uterine  erethism  is  a physiological  problem  which  will,  probably, 
never  be  solved. 

[I  trust  that  the  exposition  of  the  causes  of  the  function,  both  as  to  its 
regularity  and  , nature,  given  in  a preceding  page,  and  which  has  the  sanction 
of  MM.  Negrier,  Gendri.n,  Bischoff,  Lee,  &c.,  will  be  found,  by  most  read- 
ers, sufficient  to  remove  the  doubt  and  uncertainty  above  expressed  upon  the 
subject. — M.l 

In  some  rare  cases  the  flow  never  appears,  and  it  may  be  so  with- 
out any  evil  consequences.  This  condition,  which  in  nowise  implies 
the  nullity  of  the  venereal  appetite,  nor  even  the  existence  of  sterility, 
is  sometimes  met  with  in  women  whose  sexual  organs  are  in  a nor- 
mal condition,  and  present  no  physical  obstacle  nor  chronic  affection 
to  account  for  the  want  of  a secretion  which  appears  to  be  inherent 
in  the  nature  of  marriageable  women. 

As  the  menstrual  office  is  liable  to  frequent  derangement,  it  may 
present  phenomena  requiring  both  assiduous  and  intelligent  care. 
These  alterations  in  the  discharge  are  not,  properly  speaking,  dis- 
eases, but  symptoms  of  lesion  of  the  organs  charged  with  the  elimi- 
nating office.  The  indications  of  treatment,  therefore,  will  be  drawn 
from  the  state  of  these  organs  themselves,  or  that  of  such  as  are  sym- 
pathetically involved.  As  we  shall  be  obliged  to  occupy  the  reader’s 
attention  with  the  disorders,  irregularities  and  deviations  of  menstrua- 


PHENOMENA  OF  GESTATION. 


35 


tion,  we  refer  him  to  the  future  chapters  that  will  be  found  to  treat 
of  the  difficulty,  the  suppression,  the  immediate  discharge  or  supple- 
mentary haemorrhage  of  menstruation,  and  which  are  scientifically 
denominated  dysmenorrhcea , arnenorrhcea , menorrhagia,  or  meno- 
xenia. 


PHENOMENA  OF  GESTATION. 

Physical  and  moral  changes  that  take  place  in  gestation.  Diseases  to  which  preg- 
nant women  are  liable  in  the  various  stages  of  pregnancy. 

All  the  phenomena  of  which  we  have  now  given  a slight  sketch, 
are  but  the  prelude  to  the  admirable  part  the  uterus  is  destined  to  act 
after  the  occurrence  of  conception. 

In  this  new  condition,  it  would  seem  to  concentrate  every  thing 
upon  itself.  This  is  the  period  in  which  woman  is  called  to  the  ful- 
filment of  her  most  important  task.  The  vital  forces  are  concentrated 
upon  a single  organ ; the  conservative  efforts  then  become  less  ener- 
getic, the  reaction  of  the  body  less  powerful,  and,  consequently,  the 
impression  of  extrinsic  agents  becomes  more  lively  and  redoubtable. 

Scarcely  has  conception  taken  place  when  the  vital  forces  of  the 
womb  assume  new  strength,  and  radiate  to  the  rest  of  the  economy 
the  most  extraordinary  sympathies  and  the  most  powerful  reactions. 
The  relations  of  the  womb  with  the  brain  appear  to  become  more 
intimate ; the  circulatory,  the  digestive  and  the  respiratory  organs 
are  subjected  to  an  unusual  stimulation,  and  their  sympathy  with  the 
gestative  organs,  whether  greater  or  less,  is  announced  by  syncope, 
convulsions,  faintness,  dyspnoea,  disgusts,  and  perverted  appetite ; 
by  spasmodic  colic  and  a variety  of  other  appearances  which  are 
also  signs  of  pregnancy.  The  nervous  susceptibility  is  augmented, 
the  inclinations  and  passions  are  changed,  the  sensations  become 
more  acute,  and  the  force  of  the  intellectual  faculties  is  sensibly 
increased  on  the  one  hand,  or,  on  the  other,  lessened ; the  imagina- 
tion is  more  excitable  and  the  judgment  less  sound.  Women  have 
been  found  to  become  insane  in  pregnancy,  some  have  become  musi- 
cians or  poets,  and  some  have  acquired  a thievish  propensity.  Their 
will  loses  its  strength ; their  affections  are  less  constant ; antipathies, 
anger  and  even  cruelty  are  occasionally  met  with  in  the  sex,  whose 
natural  and  inherent  inclinations  are  marked  by  gentleness,  goodness, 
compassion,  tenderness,  an  exquisite  sensibility,  and  the  most  eager 
desire  to  console  the  unhappy. 

The  womb  having  acquired,  in  its  new  estate,  an  incomparably 
greater  vitality,  there  occurs,  in  the  pregnant  woman,  a considerable 
number  of  modifications,  both  anatomical  and  physiological. 

Some  of  these  modifications,  constituting  in  themselves  the  preg- 
nancy, must  be  respected ; but  others  of  them,  that  are  merely  sym- 
pathetic or  physiological,  are  divided  into  three  classes.  In  the  first 
class  are  placed  those  that  we  call  nervous , to  wit,  vomiting,  syncope, 
depraved  appetite,  nausea,  anorexia,  vigilance,  toothache,  ptyalism, 
headache,  palpitations,  tinnitus  of  the  ears,  deafness,  mastodynia, 


36 


PHENOMENA  OF  GESTATION. 


cough,  dyspnoea,  pains  in  the  limbs  and  groins,  heartburn,  diarrhoea, 
constipation  and  nervous  colic. 

Those  of  the  second  class,  which  we  denominate  plethoric,  are 
noticed  in  the  second  stage  of  pregnancy,  that  is,  from  the  end  of  the 
third  to  the  fifth  month.  Among  these  may  be  mentioned  uterine 
haemorrhage,  epistaxis,  piles;  sometimes  varices  and  oedema  of  the 
inferior  extremities;  haemoptoe, cough,  dyspnoea;  and,  lastly,  abortion. 

The  modifications  of  the  third  class,  which  we  call  mechanical , are 
met  with  towards  the  close  of  pregnancy:  in  this  list  we  place  ante- 
version  and  retroversion  of  the  womb,  hernia  of  the  womb,  its  pro- 
lapsion,  its  obliquity,  its  relaxation,  to  which  must  be  added  moles, 
abortion,  colic,  dysury,  constipation,  dyspnoea,  varix,  piles  and  oede- 
ma, with  a number  of  other  atfections  which  neither  can  nor  ought 
to  be  treated,  but  whose  too  violent  symptoms  may  be  palliated  by 
reasonable  methods,  at  the  risk  of  seeing  them  reproduced  at  every 
step  of  the  gestation. 

[M.  Colombat  ought  not  to  have  included  in  a list  of  affections  met  with 
near  the  close  of  gestation,  either  the  retroversion  of  the  womb,  then  an 
impossible  occurrence,  or  abortions,  which  are  always  supposed  of  the 
embryo  and  not  of  the  child. — M.] 

After  having  been  for  nine  months  exposed  to  all  the  inconveni- 
ences of  pregnancy,  the  woman  at  length  reaches  the  term  of  utero-ges- 
tation,  when  the  foetus  and  after-birth  are  expelled  with  severe  pain. 
At  this  moment  a complete  cessation  takes  place  of  the  connection 
of  the  foetus  with  its  mother ; the  womb  contracts,  the  walls  of  the 
abdomen  shrink  back  to  their  pristine  form  and  dimensions,  the 
breasts  enlarge,  a secretion  of  milk  takes  place,  and  at  last  all  the 
organs  recover  their  natural  estate. 

The  diseases  of  lying-in  women  are  numerous,  some  of  them  being 
chirurgical  and  some  medical.  Among  the  former  are  found  lacera- 
tions of  the  womb  or  perineum,  contusions  of  the  vagina  and  of  the 
vulva,  prolapsus  of  the  rectum,  vesico  and  recto-vaginal  fistulas, 
inversion  of  the  womb  and  other  physical  lesions,  which  require  the 
surgical  aids  which,  in  a later  chapter,  will  be  set  forth  and  explained. 

Among  the  second,  which  comprise  vital  lesions  belonging  to  the 
province  of  medical  practice  properly  so  called,  are  observed  acute 
metritis,  puerperal  peritonitis,  the  suppression  or  the  immoderate  flow 
of  the  lochia,  milk  fever  and  weed,  inflammation  of  the  mammary 
gland,  dysury,  strangury,  ischury,  puerperal  engorgement  of  the  infe- 
rior extremities,  and,  in  fine,  the  various  hagmorrhages  that  occur 
before,  during  and  after  delivery. 

Notwithstanding  it  may  be  difficult  to  point  out  a treatment  com- 
mon to  all  these  maladies,  as  various  as  they  are  numerous,  it  is  easy 
to  observe  that  most  of  them  affect  the  inflammatory  character,  de- 
pending, probably,  upon  the  sudden  plethora  resulting  from  the  less- 
ened extent  of  the  sanguine  circle  immediately  consequent  to  delivery. 

Under  such  a view,  might  we  not  say  that  the  most  rational  treat- 
ment, one  that  will  generally  suit  the  case,  is  an  antiphlogistic  one, 


OF  THE  CESSATION  OF  THE  MENSES. 


37 


modified  according  to  circumstances,  such  as  the  strength  of  the  patient 
and  the  losses  she  may  have  sustained  in  labour  ? 

When  nature’s  object  has  been  attained,  says  Roussel,  she  seems 
to  neglect  the  means  by  which  she  has  fulfilled  it,  the  woman 
gradually  loses  her  bloom — that  delicate  flower  of  the  constitution, 
which  buds  and  blossoms  in  early  youth,  vanishes  as  the  morning 
dew.  The  expansive  force,  whence  the  organisms  deduced  their 
tints  and  their  seductive  forms,  becomes  relaxed,  and  a disagreeable 
flaccidity  would  succeed  the  supple  and  elastic  firmness  which  marked 
them  were  they  not  sustained  by  the  embonpoint  which  generally 
accompanies  the  adult  age  and  deceives  by  a certain  air  of  freshness. 

This  change  in  the  physical  character  of  the  woman  does  not 
always  take  place  so  suddenly;  it  frequently  happens  that  the  con- 
jugal union  and  its  consequences  make  upon  the  constitution  an 
impression  favourable  to  the  beauty  of  the  female.  Nevertheless,  the 
frequent  reiteration  of  the  erotic  spasm,  conception,  pregnancy  and 
lactation,  which  are  the  consequences  of  marriage,  have,  on  most 
women,  the  effect  of  lessening  the  bloom  of  the  skin  and  the  resili- 
ency of  the  cellular  tissue.  Those  especially  who  are  of  an  amorous 
temperament,  who  have  too  much  sensibility,  soon  lose  their  fresh- 
ness and  witness  an  early  loss  of  the  beautiful  contour  which  persists 
for  a long  time  in  such  as  are  of  a cold  and  unexcitable  constitution. 

Without  ceasing  to  love,  the  female  arrives  at  length  at  a calmer 
and  happier  state ; having  become  both  wife  and  parent,  she  finds 
new  duties,  she  experiences  new  sentiments;  thus,  the  love  of  off- 
spring, her  conjugal  tenderness,  the  education  of  her  children,  the 
management  of  her  domestics,  are  the  sole  objects  that  attract  her 
regard  and  fill  up  her  happy  existence.  It  is  then  that  she  has  come 
to  the  possession  of  the  purest  happiness,  a happiness  connected  with 
the  love  of  her  family  and  secured  by  the  moral  qualities  inherent  in 
her  sex. 


OF  THE  CESSATION  OF  THE  MENSES. 

Physical  and  moral  changes  effected  by  the  cessation  of  the  menses  in  women. 
Diseases  to  which  they  are  liable  at  the  critical  period  and  during  the  subsequent 
advance  of  old  age. 

Scarcely  have  the  reproductive  faculties  ceased  from  their  state  of 
active  existence,  when  the  expansive  forces  of  her  economy  become 
lessened  and  enfeebled.  The  woman  begins  to  lose  the  hue  and  the 
blossom  of  life,  which  had  opened  under  the  expansive  age  which 
gives  power  to  the  circulation  of  the  blood  and  juices ; her  complex- 
ion fades  and  gives  way,  and  the  disagreeable  impression  of  wrinkles 
has  taken  the  place  of  those  enchanting  outlines  and  that  elastic  firm- 
ness which  characterized  the  surface  of  the  skin.  She  now  resem- 
bles a dethroned  queen,  or  rather  a goddess  whose  adorers  no  longer 
frequent  her  shrine.  Should  she  still  retain  a few  courtiers,  she  can 
only  attract  them  by  the  charm  of  her  wit  and  the  force  of  her  talents. 
Yet  women  are  met  with  who  preserve  for  a long  time  a part  of  the 
attractiveness  of  their  youthful  age,  by  means  of  a certain  fulness 


38 


OF  THE  CESSATION  OF  THE  MENSES. 


and  embonpoint  which,  while  it  can  have  no  comparison  with  the 
suppleness  and  freshness  of  youth,  may  yet  serve  to  preserve  the  out- 
line to  a certain  extent,  and  leave  them  the  possession  of  attractions 
still  capable  of  inspiring  the  tender  passion  of  love. 

Old  age,  always  early  for  women,  does  not  always  commence  as 
soon  as  they  become  absolved  of  all  obligation  as  regards  the  species. 
She  still  has  left  a space,  doubtless  all  too  short,  in  which  she  may 
yet  interest  by  the  remnants  of  those  charms  that  serve  to  recall  the 
memory  of  those  she  has  lost  for  ever. 

After  having  been  exposed  to  a thousand  infirmities  at  the  first 
eruption  of  the  catamenia,  during  the  season  of  their  perfect  establish- 
ment, at  every  return,  during  her  pregnancies,  and  in  her  season  of 
lactation,  there  remains  for  the  female  a period,  more  or  less  stormy, 
of  life,  to  which  she  always  looks  forward  with  dismay,  because  it  is 
accompanied  with  certain  affections  and  maladies  much  more  rarely 
met  with  during  the  adult  age. 

This  period,  so  cruel  for  the  female,  whom  it  deprives  of  her  beauty 
and  her  charms,  is  called  the  critical  age , the  climacteric , the  turn 
of  life , the  change  of  life:  and  is  announced  by  the  more  or  less 
sudden  cessation  of  the  menses,  and  takes  place  in  this  climate  be- 
tween the  forty-fifth  and  fiftieth  year  of  her  age. 

Like  the  first  appearance,  so  the  cessation  of  the  periods  varies  in 
different  subjects,  and  is  in  subordination  to  the  temperament,  the 
constitution,  the  climate  and  the  habit  of  life  of  the  female.  The 
connection  existing  between  the  first  and  the  last  menstruation  has 
not  escaped  the  view  of  the  observant  physician,  and  every  one  is 
aware  that  the  cessation  is  at  a later  period,  in  proportion  as  the 
eruption  was  less  precocious.  Indeed,  there  is  as  great  a difference 
in  regard  to  the  manner  of  the  cessation  as  there  is  in  that  of  the  first 
establishment.  In  our  temperate  climate,  however,  it  is  prolonged 
to  the  age  of  forty-five  or  fifty  years.  This  correspondent  duration 
of  the  fertile  age  is  what  Rod.  a Castro,  a Portuguese  physician,  who 
practised  towards  the  close  of  the  sixteenth  century,  referred  to  in  the 
Tract,  de  Mulieb.  Morb.,  lib.  ii.,  in  these  Latin  verses: — 

“Adde  decern  terms,  mulierum  menstrua  cernis 
Ad  quinquaginta  durat  purgatio  tota.” 

Samples,  however,  have  been  recorded  of  a much  later  fecundity; 
for  example,  Pliny,  the  naturalist,  says  that  Cornelia,  of  the  family  of 
the  Scipios,  became  the  mother  of  Valerius  Saturninus  at  the  age  of 
sixty-two.  Vallescus  de  Tarenta,  in  his  Course  of  Physic , published 
in  1518,  says  that  he  attended  a woman  in  labour  who  was  sixty- 
seven  years  old.  The  great  Baron  Haller  mentions  a woman  still 
regular  at  seventy,  and  brought  to  bed  at  that  age.  I myself  saw  in 
the  little  town  of  Walse,  department  of  the  Ardeche,  a woman  who 
was  very  regular,  and  who  was  confined  at  sixty-one,  aud  I may 
add,  that  one  of  my  relatives,  the  mother  of  ten  children,  whoresided 
in  the  department  of  Seine  and  Oise,  where  she  died  in  1832,  never 
ceased  from  the  age  of  eighteen  to  be  subject  to  a sanguine  discharge, 
which  took  place  regularly  every  month  to  the  seventy-third  year. 


OF  THE  CESSATION  OF  THE  MENSES. 


39 


And  lastly,  M.  Orfila  has  informed  us,  in  his  lectures,  of  a fact  still 
more  extraordinary.  A woman,  said  the  leartied  professor,  who  had 
had  seven  children,  became  pregnant  of  her  first  child  at  the  age  of 
forty-seven,  gave  birth  to  her  last  at  sixty,  was  regular  to  her  ninety- 
ninth,  and  died  at  114. 

[M.  Brierre  de  Boismont,  at  p.  209,  says,  “ It  is  generally  observed  that 
the  cessation  takes  place  in  this  country  (France)  at  about  forty-five,  sooner 
or  later.”  The  fact  is  true,  but  I think  the  appreciation  of  it  would  be 
more  perfect  in  view  of  a tabular  statement,  indicating  the  different  periods 
of  the  change  of  life.  I have  collected  183  cases  of  women  in  whom  the 
menses  had  ceased,  and  here  are  the  results. 


21 

years 

2 

37  years 

4 

48 

years 

8 

24 

it 

1 

38 

tt 

7 

49 

44 

7 

26 

tt 

1 

39 

tt 

1 

50 

44 

12 

27 

ti 

1 

40 

tt 

18 

51 

4 

28 

tt 

1 

41 

tt 

10 

52 

44 

8 

29 

ti 

1 

42 

tt 

7 

53 

44 

2 

31 

ti 

3 

43 

tt 

4 

54 

44 

5 

32 

tt 

2 

44 

tt 

13 

55 

44 

2 

34 

tt 

4 

45 

tt 

13 

56 

44 

2 

35 

tt 

6 

46 

tt 

9 

57 

44 

2 

36 

tt 

7 

47 

tt 

13 

60 

44 

1 

Total  181— M.] 

It  often  happens  that  the  discharge  is  suddenly  suppressed,  but  it 
generally  ceases  by  degrees,  and  this  successive  cessation  in  some 
cases  comprehends  the  interval  of  only  one,  and  in  others  of  six 
months.  Certain  females  are  met  with,  who  are  two  whole  years 
losing  the  attribute  of  the  sex.  If  interrogated  upon  this  point, 
many  of  them  will  not  give  a candid  answer,  for  they  desire  to  dis- 
pute every  inch  of  ground  with  the  advance  of  old  age.  They 
invariably  conceal  the  ravages  of  time,  and  converse  with  evident 
disquietude  of  the  close  of  their  spring-time  of  existence,  even  when 
the  faded  traces  of  beauty,  and  the  stealing  traces  of  grayness  in  the 
hair  proclaim  the  approach  of  winter.  Delivered  from  the  discharge 
attached  to  the  important  functions  of  the  uterus,  the  woman  loses 
along  with  it  the  power  of  conceiving,  and  ceases  thenceforth  to  exist 
as  for  the  species. 

At  this  period  she  may  be  said  to  exchange  her  own  constitution 
for  that  which  is  appropriate  to  the  male  ; but  being  of  a more  flexi- 
ble constitution,  she  is  less  exposed  than  he  to  the  assault  of  man)?’ 
maladies,  and  is  more  likely  to  run  a long  career  of  existence. 
Nevertheless,  she  certainly  does  undergo  very  remarkable  changes  in 
her  nature,  which  we  shall  distinguish,  like  those  that  occur  at  the 
other  periods  of  her  life,  as  either  physical  or  moral. 

The  womb  having  laid  aside  those  vital  properties  which  fitted  it 
for  the  act  of  reproduction,  gradually  ceases  to  react  upon  the  general 


40 


OF  THE  CESSATION  OF  THE  MENSES. 


economy,  and  takes  its  place  in  class  among  the  other  organs  whence 
it  emerged  at  puberty.'  It  diminishes  in  size,  becomes  more  dense, 
its  cervix  undergoes  a sort  of  atrophy,  and  little  by  little,  is  effaced; 
its  os  tineas  becomes  undistinguishable,  or  disappears  entirely.  At 
this  period  all  the  organic  functions  are  performed  at  a diminished 
rate.  As  the  blood  no  longer  retains  its  habitual  determination 
towards  the  organs  of  reproduction,  it  flows  more  freely  towards  the 
superior  regions  of  the  body,  where  it  gives  rise  to  vertigo,  headache, 
epistaxis  and  hot  flushings.  The  face  acquires  a purplish  hue,  the 
eyes  are  red  and  injected,  to  which  symptoms  are  added  dizziness 
and  buzzing  of  the  ears.  The  pulse  being  full  and  bounding,  indi- 
cates a plethoric  state ; the  beatings  of  the  heart  are  effected  with  a 
sort  of  distress,  the  respiration  is  not  easy,  and  the  sleep,  often  broken 
by  frightful  dreams,  does  not  serve  as  usual  to  repair  the  wasted 
strength.  In  fine,  a sort  of  uneasiness  and  restlessness  of  the  limbs 
comes  to  indicate  a state  of  great  irritability,  conjoined  with  extreme 
exhaustion.  The  pains  that  she  feels  in  the  loins  and  in  the  lower 
part  of  the  abdomen,  are  accompanied  with  intolerable  and  vexa- 
tious itching  about  the  vulva  and  fundament.  The  skin  rapidly 
loses  its  colour  and  suppleness,  becomes  wrinkled  and  sallow ; the 
hair  falls  off  or  turns  gray,  the  breasts,  which  at  first  become  flaccid 
and  pendulous,  at  length  disappear  entirely;  the  perspiration  lessens 
in  quantity,  the  urine  increases  in  abundance,  the  voice  changes  and 
resembles  more  nearly  that  of  the  male,  and  all  the  graceful  and  soft 
contours  of  the  gentle  sex  disappear,  to  be  replaced  by  a wrinkled 
surface. 

Some  women  get  happily  through  the  change  of  life,  especially 
such  as  were  always  thin  and' delicate  before,  who  have  the  con- 
stitution completely  changed,  and  so  greatly  strengthened,  that  the 
most  perfect  health  and  plumpness  seem  to  restore  to  them  the  ele- 
gance of  figure  and  form  they  enjoyed  in  the  spring-time  of  their 
days,  and  almost  to  re-establish  the  polished  and  finished  air  of  youth. 

The  moral  character  of  the  female  is  sometimes  even  more  affected 
by  the  change  than  her  physical  constitution.  She  becomes  sad, 
restless,  taciturn,  she  regrets  her  lost  power  to  please,  the  enjoyments 
that  are  gone  forever,  and  the  future,  which  she  views  clothed  in  the 
most  sombre  hues.  Some  among  them,  who  were  always  good,  sweet- 
tempered  and  patient,  become  sour,  excitable,  irascible ; often  fall- 
ing into  passion  without  provocation,  they  become  unjust  towards 
every  body ; they  issue  their  orders  with  sharp  tones,  and  treat  every 
body  about  them  with  severity.  In  others,  the  sensibility  increases  as 
it  did  at  puberty,  and  they  are  pestered  with  vapours  and  hysteri- 
cal paroxysms,  or  tyrannized  by  the  memory  of  past  love,  seek  to 
extinguish  their  ardour  in  new  sources  of  enjoyment.  This  resur- 
rection of  the  desires  and  passions  almost  always  leads  to  bitter 
remorse,  and  to  the  most  formidable  results. 

In  spite  of  the  loss  of  all  her  physical  advantages,  the  aged  woman 
who  is  endowed  -with  sense  and  wit,  and  who  renounces  all  vain 
pretensions,  and  lays  aside  all  coquetry,  finds  it  in  her  power,  by 


OF  THE  CESSATION  OF  THE  MENSES. 


41 


numerous  admirable  qualities,  to  become  more  worthy  than  ever  of 
the  warmest  friendship  and  confidence  of  the  male,  whose  lover  she 
is  not,  but  to  whom  she  is  a sincere  and  consolatory  friend.  At  this 
period  the  qualities  of  her  soul  are  greatly  perfected ; the  passions 
that  long  agitated  her  bosom  have  purified  her  heart,  which  becomes 
steady,  so  that  her  friendship  is  immovable,,  and  capable  of  the 
greatest  sacrifices.  Together  with  a new  existence,  she  regains  a 
new  dominion  over  all  that  surround  her,  and  her  empire,  which 
was  previously  circumscribed  by  the  narrow  circle  of  a few  men, 
now  comprehends  within  its  circumference  even  the  women  who 
have  ceased  utterly  to  be  classed  among  her  rivals. 

The  unhappy  victims  of  a life  of  celibacy,  those  whose  lives  have 
been  agitated  by  the  liveliest  passions,  by  numerous  vexations  or 
excess  of  pleasures,  are  generally  more  violently  and  painfully  shaken 
at  the  crisis  than  such  as  have  made  a better  use  of  their  existence. 

Dr.  Moreau  de  la  Sarthe,  the  elegant  and  spirited  author  of  the 
Hist.  Natur.  de  la  Femme , justly  remarks  that  two  circumstances 
are  worthy  of  observation,  among  the  numerous  differences  presented 
by  the  change  of  life  in  those  women  who  have  not  passed  easily 
and  naturally  through  the  revolution. 

“ The  first  is  that  of  a stormy  suppression,  the  consequence  of  an 
excess  of  strength  and  vitality  in  the  womb,  which  with  difficulty 
renounces  its  habits  of  exaltation,  and  in  its  last  effort  to  preserve  its 
empire  and  predominance  of  action,  overthrows  the  whole  living 
system,  and  gives  rise  especially  to  nervous  disorders,  and  a profound 
change  in  the  powers  of  the  digestive  apparatus.  When  the  cessa- 
tion takes  place  in  so  unfavourable  a manner,  women  observe  that 
their  habitual  indispositions  become  more  frequent  and  serious.  All 
their  functions  are  more  or  less  disordered  and  irregular.  The  com- 
plexion acquires  an  unhealthy  tint,  or  a bilious  hue,  and  transitory 
flushings  of  the  face  are  frequently  felt,  so  that  the  countenance  at 
last  becomes  permanently  reddened  all  over,  or  in  patches  of  colour 
seated  on  a dark  and  sallow  ground.  She  also  suffers  under  some 
other  more  or  less  serious  ailments.  A painful  sensation  in  the  loins 
and  in  the  region  of  the  womb,  sadness  and  depression,  rebellious 
vigils,  strange  and  fatiguing  dreams,  swelling  of  the  joints,  &c. 

“ The  other  circumstance  consists  in  too  prompt  a cessation ; one 
so  sudden  and  unexpected,  that  she  mistakes  it  for  a simple  suppres- 
sion. Such  a case  is  always  serious,  as  are,  for  the  most  part,  all 
suppressions  of  habitual  discharges  that  do  not  take  place  gradually, 
when  they  are  of  a kind  that  exert  considerable  influence  on  the 
constitution.  These  sudden  revolutions  commonly  lead  to  a general 
disorder  of  the  health,  whose  real  cause  is  apt  to  be  misapprehended, 
or  they  lay  the  foundation  of  disease  in  the  organ  itself,  whose  weak- 
ness and  unsteady  vital  rate  become  the  sources  of  multiplied  acci- 
dents and  infirmities. 

“ The  haemorrhages  that  supervene  in  such  cases  are  mostly  accom- 
panied, or  even  preceded,  by  sharp  and  pungent  pains  in  the  region 
of  the  womb,  and  are  also  followed  by  the  symptoms  usually  apper- 
taining to  such  incidents  of  disease.  Differences  in  constitution, 


42 


OF  THE  CESSATION  OF  THE  MENSES. 


whether  natural  or  acquired,  must  effect  numerous  diversities  in  the 
mode  in  which  women  come  to  the  complete  change  of  life” 

This  picture  of  the  phenomena  that  accompany  the  close  of  men- 
struation, is  but  a version  of  that  drawn  by  Dr.  Fothergill,  in  the  first 
volume  of  the  Trans,  of  the  Med.  Soc.  of  London.  The  celebrated 
English  physician  also  thought,  and  very  justly,  that  the  sudden  ces- 
sation produced  symptoms  the  more  alarming  if  the  female  had 
habitually  made  an  improper  use  of  pleasure,  if  she  had  had  but  few 
children,  if  barren,  and  lastly,  if  she  had  laboured  under  herpetic 
affections,  or  neglected  syphilitic  disorders. 

There  are  a great  number  both  of  local  and  general  disorders  that 
may  help  to  cast  a deeper  shade  over  the  picture  of  the  female  crisis. 
Scirrhus,  cancer  of  the  womb,  vagina  or  rectum,  of  the  breast  and 
ovary;  dropsy  of  the  ovarium,  or  the  Fallopian  tube;  chronic  metri- 
tis, uterine  haemorrhage,  fibrous  tumours  and  polypus  of  the  vagina 
or  womb  ; ulcerations  and  catarrhs  of  these  parts;  and,  in  fine,  nume- 
rous other  local  and  general  affections,  are  the  mournful  appurte- 
nants of  a woman  at  the  change.  Considering  all  the  various  modi- 
fications of  the  economy  of  the  female  that  take  place  under  the 
. influence  of  the  womb,  might  we  not  venture  to  say,  with  Van  Hel- 
mont,  Propter  uterum  mulier  id  est  quod  est ; and  with  Hippo- 
crates, Propter  uterum  mulier  tota  morbus  est? 

Notwithstanding  the  female  grows  old  earlier  than  the  male,  a 
greater  number  of  examples  of  longevity  is  found  among  women 
than  among  men,  except,  indeed,  a few  very  rare  cases  of  extraor- 
dinary longevity,  which  are  always  found  to  occur  in  persons  of  our 
own  sex.  The  numerous  researches  that  have  been  made  as  to  the 
mortality  among  women,  and  particularly  at  the  period  called  change 
of  life,  prove  that  this  period,  which  they  look  upon  as  so  dangerous, 
is  in  fact  not  more  critical  for  them  than  for  us,  and  does  not  show  a 
greater  ratio  of  mortality  for  females  than  for  meri.  Muret,  in  his 
work  on  the  Population  of  the  Pays  de  Vaud , did  not  find  that 
from  forty  to  fifty  was  more  dangerous  to  females  than  from  the 
tenth  to  the  twentieth  year  of  age ; and  M.  Benoiston  de  Chateau- 
neuf,  who  has  also  made  very  elaborate  researches  on  the  same  sub- 
ject, read  an  interesting  memoir  at  the  Acad,  of  Scien.,  in  ISIS, 
which  contains  results  as  follows : 

“ From  the  fortieth  to  the  sixtieth  degree  of  latitude,  on  a line 
extending  through  Vevay,  Paris,  Berlin  and  Stockholm,  we  can  dis- 
cover at  no  period  of  the  life  of  the  female,  from  her  thirtieth  to  her 
seventieth  year,  any  other  increase  in  the  ratio  of  mortality  than  that 
necessarily  determined  by  the  progressive  advance  of  age.*  At  every 
epoch  of  the  life  of  the  male,  from  the  thirtieth  year  to  the  seventieth, 
the  mortality  exceeds  that  of  the  other  sex,  but  especially  from  forty 
to  fifty  years  of  age.  It  follows,  then,  that  the  age  from  forty  to  fifty 
is  more  dangerous  for  men  than  for  women,  and  that  too  without 
reference  to  the  kind  of  life  they  lead,  whether  in  town  or  country, 
in  the  camp  or  the  cloister.  But,  as  it  cannot  be  denied  that  women 
do  die  between  the  fortieth  and  fiftieth  year  of  the  consequences  of 
their  .great  physiological  change  under  consideration,  and  us  in  spite 


OP  THE  CESSATION  OF  THE  MENSES. 


43 


of  this  cause  of  mortality,  not  to  be  found  in  the  other  sex,  their 
decrease,  instead  of  being  greater,  is  actually  less  than  that  of  the 
male,  what  power  and  duration  of  life  would  be  theirs,  were  it 
not  for  this  condition  which  nature  has  appended  to  their  sexual 
character  ?” 

At  Paris,  and  at  all  the  great  cities,  where  the  causes  of  hygienic 
perturbations  are  very  abundant,  and  constantly  renewed,  the  women 
use  up  their  day  of  youth  and  expend  their  vital  power  almost  with- 
out perceiving  it.  They  are  surrounded  by  many  circumstances  cal- 
culated to  hasten  the  approach  of  old  age  and  lessen  the  duration  of 
life.  We  intend  to  speak  at  large  on  this  subject,  in  that  portion  of 
this  work  that  treats  on  the  hygiene  of  the  sex,  as  applicable  to  all 
the  periods  of  their  life. 

Having  now  sketched  a picture  of  the  changes  that  take  place  in 
women,  and  having  indicated  the  peculiar  diseases  to  which  they  are 
principally  exposed  at  the  different  phases  of  their  existence,  we  shall 
proceed  to  say  a few  words  upon  the  surgical  anatomy  and  the  vari- 
eties of  conformation  of  the  genitalia,  and  upon  the  sympathies  of 
the  womb. 


CHAPTER  II. 


OF  THE  VARIETIES  OF  CONFORMATION,  THE  SURGICAL  ANATOMY  OF  THE  GENITAL 
ORGANS,  AND  THE  SYMPATHIES  OF  THE  W(MB. 

As  the  external  genitals  of  the  female  present  no  anatomical  cha- 
racter that  is  not  familiar  to  all  physicians,  we  shall  here  confine  our- 
selves to  the  duty  of  describing  only  such  varieties  of  conformation 
as  they  may  present  according  to  differences  of  age,  climate  and 
constitution,  and  we  shall  indicate  especially  those  points  in  their 
surgical  anatomy,  the  knowledge  of  which  is  important  as  throwing 
light  upon  some  points  of  the  diagnosis,  as  well  as  simplifying  some 
of  the  operations  that  are  required  in  the  treatment. 

In  southern  climes  the  sexual  parts  are  found  a little  higher  up  and 
more  in  front  than  in  cold  and  damp  countries.  Thus,  in  the  Scot- 
tish, English  and  Dutch  women,  the  vulva  is  not  so  directly  in  front, 
and  the  womb  is  lower  down  than  in  the  French  women  of  the 
southern  departments,  the  Spaniards  and  the  Italians.  The  latter 
are  known  to  have  the  labia  of  a more  rounded  form,  and  containing 
a more  abundant  and  elastic  cellular  tela. 

[This  remark  has  been  made  by  other  writers ; but  it  is  difficult  to 
imagine  that  any  other  foundation  for  it  can  exist  than  the  imagination. 
The  human  pelvis  is  very  much  alike  all  the  world  over,  and  since  the 
genitalia  are  founded  upon  the  bones  of  the  ossa  pubis,  how  can  it  be  that 
such  differences  as  those  described  by  the  author  are  to  be  reconciled  with 


44 


VARIETY  OF  FORM 


the  anatomical,  or  rather  the  osteological  basis  of  these  formations.  In  all 
women,  except  those  in  whom  the  external  genitalia  have  been  injured  and 
relaxed  by  repeated  acts  of  parturition,  by  the  relaxation  of  age,  emaciation, 
debility  and  accidents,  the  posterior  commissure  of  the  genital  fissure,  coin- 
cides with  the  top  of  the  pubic  arch  ; but  as  the  symphysis  pubis  is  but  an 
inch  and  a quarter  to  an  inch  and  a half  long,  all  the  world  over,  it  is  clear 
that  the  author  is  under  some  mistake  in  making  out  his  point  above  stated. 
To  suppose  him  correct  is  to  suppose  that  the  southern  women  have  very 
deep  pubic  symphyses,  or  that  the  plane  of  the  superior  strait  dips  at  a 
lesser  angle  under  the  horizon,  which  is  inadmissible. — M.] 

In  young  females,  the  labia  are  thicker  above  than  below,  in  which 
respect  they  differ  from  those  of  women  who  have  borne  children. 
In  early  life  these  two  folds  are  not  so  near  together  as  at  a later 
period,  although  they  are  more  prominent  and  of  a larger  size  rela- 
tively. At  the  age  of  puberty  they  are  in  mutual  contact  closing  the 
genital  fissure,  and  are  also  of  a firmer  texture  than  at  any  other 
period.  In  married  life,  and  particularly  after  parturition,  the  labia 
becomes  soft  and  pendent,  and  lose  their  original  form  and  even- 
ness. The  mucous  membrane  that  lines  the  interior  surface  is  of  a 
lively  red  in  the  virgin,  but  acquires  a brownish  and  violaceous  hue 
in  such  as  have  been  the  frequent  subjects  of  the  coitus,  and  who 
have  had  many  children. 

At  birth  the  nymphae  generally  project  beyond  the  level  of  the 
labia — in  young  virgins  the  labia  conceal  them,  but  they  again 
become  salient  in  child -bearers.  In  the  commencement,  from  being 
firm,  erectile  and  of  a rosaceous  hue,  they  grow  flaccid,  and,  like  the 
mucous  membrane  of  the  labia,  turn  soft,  brown  or  violet-coloured, 
and  offer  a greater  variety  of  appearances  than  the  labia  do  in  differ- 
ent races  and  climates.  Among  the  Turkish  and  Persian  women  the 
nymphae  are  naturally  much  more  prominent  than  in  our  European 
regions,  and  in  some  of  them  they  grow  so  very  large  as  to  obstruct 
the  entrance  and  constitute  a disorder  so  disgusting  that  it  is  removed 
by  means  of  the  excision  of  the  swollen  part.  Ten-Rhine,  Tackard, 
Sparmann,  Banks,  Peron,  Le  Sueur  and  most  of  the  naturalists  have 
spoken  of  a very  considerable  elongation  of  the  nymphae,  which  is 
known  as  the  tab  tier  des  Hottentottes,  or  Hottentot  apron , and 
which  seems  to  be  a conformation  natural  to  the  Bosjesman  women 
of  Southern  Africa.  Levaillant  says  that  this  hideous  conforma- 
tion, this  sort  of  fleshy  apron  of  the  Hottentots  is  not  an  elongation  of 
the  nymphae,  but  of  the  labia  themselvesj  which,  according  to  his 
account,  grow  to  the  length  of  eight  or  nine  inches. 

The  uses  of  the  nymphae  are  but  little  understood.  The  ancients 
conferred  upon  them  the  name  of  nymphae,  in  allusion  to  the  fabulous 
nymphs  who  presided  over  springs  and  fountains.  Most  of  the 
accoucheurs  suppose  that  their  use  consists  in  giving,  by  their  unfold- 
ing in  labour,  more  material  for  the  distension  of  the  external  parts. 
It  has  also  been  said,  that  as  they  are  endowed  with  the  highest 
sensibility,  they  contribute  to  augment  the  sexual  excitement.  The 


OF  THE  EXTERNAL  GENITALS. 


45 


learned  academician,  M.  Serres,  supposes  that  during  the  act  of 
copulation,  the  nymphse  being  forced  backwards  into  the  vagina, 
their  upper  extremity,  which  surrounds  the  clitoris  as  a preputium 
clitoridis,  is  drawn  forwards  and  downwards  so  as  to  compel  the 
clitoris  to  toucfy  the  dorsum  penis,  which  occasions  a much  more 
intense  erotic  sensation. 

Like  the  other  parts  of  the  external  genitalia,  the  clitoris  is  found 
to  be  the  subject  of  differences  which  are  worthy  of  mention.  This 
exquisitely  sensitive  point,  which  has  been  compared  to  the  uvula, 
and  which  is  like  a miniature  penis,  is  relatively  much  larger  at  birth 
than  at  any  other  period. 

[It  is  difficult,  in  the  early  embryonic  stages,  to  detect  the  difference  of  the 
sexes,  in  consequence  of  the  similitude  of  the  penis  and  the  clitoris. — M.] 

It  soon  ceases  to  increase  in  size,  and  at  puberty  is  commonly  four 
or  five  lines  in  length.  But  in  a few  cases,  women  are  to  be  met 
with,  in  whom  the  clitoris  is  six  inches  long,  which  gives  it  a con- 
siderable resemblance  to  the  male  organ.  This  state  of  the  case 
generally  gives  rise  to  a suspicion  of  hermapbrodism,  and  is  observed 
in  women  of  a very  masculine  character,  and  who  prefer  the  kind  of 
occupations  generally  devolved  upon  men  alone.  Such  women  com- 
monly have  very  small  breasts,  but  the  muscular  and  pilous  systems 
are,  on  the  other  hand,  greatly  developed.  The  upper  lip  and  chin 
are  bearded,  they  are  of  tall  stature,  and,  in  fact,  they  seem  to  belong 
really  to  neither  of  the  sexes,  and  are  said  even  to  be  fond  of  the 
illicit  enjoyment  of  other  females. 

[I  do  not  feel  that  I have  the  right  to  doubt  the  above  remarks,  but  I can- 
not refrain  from  saying,  that  they  can  have  no  other  foundation  than  the 
imagination  of  authors  by  whom  they  have  been  reiterated,  and  need  only 
suggest  to  the  medical  reader,  that  such  a clitoris,  even  if  slightly  endowed 
with  erectile  properties,  can  by  no  means  be  supposed  capable  of  such  a 
state  as  to  admit  the  possibility  of  so  revolting  an  act.  It  is  true  that  there 
are  the  corpora  cavernosa  clitoridis,  but  as  there  is  no  corpus  spongiosum, 
nor  glans,  and  as  the  clitoris  in  question  is  a case  of  diseased  hypertrpohy, 
the  notion  repeated  by  our  author  must  be  without  real  foundation,  in  the 
anatomical  nature  of  the  part. — M.] 

If,  as  is  generally  believed,  the  frequency  of  conception  is  in  a 
direct  ratio  to  the  intenseness  of  the  erotic  excitement  in  the  sexual 
combination,  it  is  a consideration  of  much  importance  in  surgery  to 
respect,  as  far  as  possible,  both  the  clitoris  and  the  nymphse,  which, 
in  consequence  of  their  sensitive  endowments,  appear  to  be  the  prin- 
cipal seats  of  the  erotic  excitations. 

In  its  anatomico-chirurgical  regards,  the  vestibulum  presents  no- 
thing of  interest,  excepting  that  it  is  the  point  at  which  both  Celsus 
and  M.  Lisfranc  have  advised  us  to  open  the  bladder  for  the  extrac- 
tion of  a calculus. 

There  are  several  anatomical  varieties  of  the  urethra,  especially  at 
its  external  orifice.  This  canal  has  been  seen  to  open  into  the  vagina, 


46 


VARIETY  OF  FORM 


into  the  rectum,  and  even  on  the  mons  veneris.  There  are  some 
females  with  the  vulva  very  small,  even  though  they  may  have  been 
subject  to  the  coitus,  in  whom  the  orifice  is  far  back,  behind  the 
symphysis  of  the  pubis. 

In  such  case  it  would  be  impossible  to  apply  the  catheter,  unless, 
by  introducing  the  index  upwards  and  backwards,  the  surgeon  should 
first  draw  the  urethra  downwards  and  forwards  to  expose  its  orifice. 

The  perineum,  that  is  to  say,  the  space  betwixt  the  anus  and  the 
vulva,  is  smaller  than  is  commonly  supposed;  when  it  seems  to  pos- 
sess an  antero-posterior  diameter  greater  than  common,  it  happens 
so  because  its  anterior  margin  is  prolonged  by  means  of  a sort  of 
transverse  band,  thin  from  above  downwards,  and  slightly  concave 
forwards,  terminating  in  a thin  membranous  edge,  beyond  which  the 
fossa  navicularis  is  situated.  From  this  anatomical  arrangement,  it 
happens  that  the  longer  the  perineum,  the  shorter  seems  to  be  the 
genital  fissure,  and  vice  versa.  The  perineum,  in  reality,  is  always 
of  the  same  extent,  and  it  is  only  this  prolongation  of  its  transversal 
fold  that  varies,  and  that  sometimes  augments  its  antero-posterior 
diameter.  We  have  deemed  it  proper  to  mention  this  circumstance, 
in  order  to  show  that  whenever,  for  certain  surgical  purposes,  it 
might  be  judged  necessary  to  increase  the  size  of  the  vulvar  opening, 
we  might  do  so  by  dividing  this  anterior  transverse  band,  without 
any  fear  of  doing  injury  to  the  true  perineum. 

OF  THE  VAGINA  AND  CERTAIN  VARIETIES  OF  CONFORMATION 
OBSERVED  IN  IT. 

There  are  varieties  of  conformation  observable  in  the  vagina,  in 
different  women,  the  knowledge  of  which  is  of  much  importance  to 
the  practitioner.  In  the  virgin  state  the  tube  is  generally  partially 
closed,  on  its  posterior  part,  by  a membrane  called  the  hymen,  which 
although  ordinarily  very  thin,  is  sometimes  found  to  be  several  lines 
in  thickness.  In  childhood  this  membrane  forms  a semilunar  fold, 
and  it  acquires  only  at  puberty,  according  to  Ruysch  and  Meckel,  a 
circular  form  in  some  specimens.  The  former  of  these  authors,  and 
some  modern  writers,  and  among  them  M.  Lisfranc,  relate  cases  in 
which  it  has  been  found  double. 

This  membranous  fold,  which  is  correctly  regarded  as  one  of  the 
best  signs  of  virginity,  is,  nevertheless,  sometimes  found  to  exist  in 
young  persons  who  have  ceased  to  be  virgins.  In  such  cases  it  has 
been  preserved  by  its  thickness  and  elasticity  from  rupture  by  the 
violence  offered  to  it.  Examples  of  this  sort  are  very  rare,  however, 
for  in  an  immense  majority  of  cases,  the  hymen  is  ruptured  at  the  first 
sexual  approaches,  and  the  fragments  into  which  it  is  then  torn  con- 
stitute certain  small  fleshy  eminences,  called  carunculae  myrtiformes, 
which  it  is  necessary  not  to  confound  with  venereal  vegetations. 
Notwithstanding  the  great  moral  importance  attached  to  the  inte- 
grity of  the  hymen,  there  are  cases  met  with  in  practice,  in  which 
the  surgeon  is  compelled  to  destroy  the  membrane,  by  means  of  an 


OF  THE  EXTERNAL  GENITALS. 


47 


operation  to  be  described  when  we  shall  have  occasion  to  speak  of 
the  indications  that  render  it  indispensably  necessary. 

The  vulvar  orifice  of  the  vagina,  which  is  not  very  dilatable  in 
young  marriageable  girls,  is  much  more  so  in  women  who  have 
borne  children,  and  its  dilatation  is  almost  null  in  women  arrived  at 
the  change  of  life,  and  especially  in  such  as  have  long  overpassed 
that  critical  period.  As  the  sexual  organs  at  this  age  have  no  func- 
tions to  fulfil,  they  become  atrophied,  the  vagina  contracts,  its  mucous 
coat,  which  was  soft  and  full  of  pleats  in  youth,  now  becomes  smooth, 
whitish  and  polished;  the  vaginal  orifice,  instead  of  being  a supple  and 
easily  dilatable  ring,  becomes  hard  and  resisting,  and  is,  in  many 
persons,  so  contracted  as  scarcely  to  admit  of  the  introduction  of  the 
little  finger. 

Instead  of  being  a cylindroid  canal,  as  it  is  described  to  be  by  almost 
all  the  anatomists,  the  upper  third  part  of  it  exhibits  a dilatation  so 
considerable  as  to  admit  of  the  finger  pressing  it  aside  in  every  direc- 
tion, and  even  of  our  examining  the  very  corpus  uteri.  The  author 
was  long  ago  acquainted  with  this  fact,  of  the  great  extensibility  of 
the  part  of  the  vagina  that  is  nearest  the  womb,  and  it  was  this 
knowledge  which  gave  rise  to  the  idea  of  his  speculum  brise,  as  well 
as  of  the  peculiar  mode  of  operating  for  amputation  of  the  cervix 
uteri.  The  superior  region  of  the  vagina,  in  its  posterior  and  lateral 
parts,  is  in  direct  relation  with  the  peritoneum,  so  that  if  the  surgeon 
should  make  a perforation  there,  he  would  inevitably  wound  the 
peritoneal  membrane  and  penetrate  the  abdominal  cavity,  whilst  a 
perforation  made  in  front  and  above,  would  penetrate  the  bas-fond 
of  the  urinary  bladder. 

Instead  of  being  inserted  horizontally  and  like  a ring  upon  the 
cervix  of  the  womb,  as  we  are  taught  by  all  the  anatomists,  the 
upper  end  of  the  vagina  is  attached  obliquely  from  behind,  forwards, 
that  is  to  say,  the  anterior  surface  is  nearer  to  the  os  tineas  than  the 
posterior.  This  arrangement,  the  knowledge  of  which  is  extremely 
important  as  regards  the  operation  for  excision  of  the  cervix  uteri, 
affords  a more  considerable  space  behind  than  is  found  in  front  of  the 
cervix.  M.  Lisfranc  found,  in  more  than  one  hundred  patients,  that 
the  breadth  of  the  vaginal  insertion  is  much  more  extensive  than  is 
generally  supposed,  and  that  it  may  vary  from  six  to  fifteen  lines. 
According  to  that  distinguished  surgeon,  the  smallest  distance  from 
the  os  uteri  to  the  peritoneum  is  nine  lines  on  its  anterior  and  ten 
lines  on  its  posterior  surface.  This  discovery  has,  on  various  occa- 
sions, enabled  him  to  cut  off  six  or  eight  lines  in  length  of  the  cervix, 
still  leaving  to  this  part  of  the  organ  a sufficiency  of  the  insertion  to 
support  the  weight  of  the  viscera.  It  is  easy  to  conceive  of  the 
advantages  arising  from  the  anatomical  disposition  we  have  just 
detailed,  and  to  appreciate  the  value  of  a correct  knowledge  of  them 
in  performing  certain  operations  upon  the  neck  of  the  womb. 

We  must  add,  moreover,  that  the  inferior  region  of  the  vagina 
is  somewhat  depressed  in  a direction  from  before  backwards,  and 
slightly  bent  towards  the  pubis.  Its  two  extremities  are  cut  obliquely 
or  beveled,  so  that  its  anterior  is  shorter  than  its  posterior  wall.  The 


48 


VARIETY  OF  FORM 


vagina  is  remarkable  for  the  property  it  possesses  of  dilating,  and 
of  rapidly  and  insensibly  acquiring  very  large  dimensions  in  every 
direction.  Tumours  are  frequently  formed  in  its  interior,  that  distend 
it  more  or  less  both  in  its  longitudinal  and  transverse  diameters;  thus 
a polypus,  whether  fibrous  or  carcinomatous,  a lipoma,  a steatoma, 
a phlegmon,  &c.  &c.,  not  unfrequently  cause  the  canal  to  acquire,  by 
degrees,  an  enormous  dilatation.  In  these  cases,  as  happens  after 
labour,  when  the  distending  cause  has  been  removed,  the  walls  con- 
tract by  degrees  and  at  length  recover  their  natural  size. 

[The  translator  requests  the  attention  of  the  reader’ to  a circumstance  in 
the  anatomical  character  of  the  vagina  that  seems  to  have  escaped  the 
observation  of  the  author  of  the  work.  It  is  this,  that  the  posterior  and 
part  of  the  lateral  walls  of  the  vagina  are  inserted  in  the  soft  and  distensible 
parts,  as  the  perineum,  while  the  anterior  and  part  of  the  antero-lateral 
walls  are  firmly  attached  to  the  pubic  arch.  Now  it  is  worthy  of  remark, 
that  when  the  womb,  in  labour,  is  pressing  the  presenting  part  of  the  child 
through  the  lower  part  of  the  vagina,  but  dilating  and  stretching  it  in  length 
to  its  utmost  capacity,  the  chief  part  of  the  strain  must  be  expended  on  the 
anterior  column  and  the  antero-lateral  walls  of  the  organ.  Hence,  if  the 
vagina  gives  way  or  becomes  lacerated,  the  rupture  will  be  most  apt  to 
commence  on  the  anterior  or  on  an  antero-lateral  surface,  which  cannot 
yield  in  length  so  freely  as  the  posterior  column  can  do,  that  being  attached 
to  the  perineum,  and  to  other  soft  and  distensible  parts. 

I have  seen  two  cases  of  labour  in  which  the  vagina  was  ruptured,  and  in 
both,  the  fracture  occurred  in  the  anterior  and  antero-lateral  surface  and  not 
behind.  Such  an  accident,  implicating  the  vesico-vaginal  septum,  could 
scarcely  fail,  except  by  merely  detaching  the  vesical  mucous  membrane, 
such  an  accident,  I say,  could  hardly  fail  to  give  rise  at  least  to  a very  bad 
case  of  vesico-vaginal  fistula.  I avail  myself  of  this  opportunity  to  recur  to 
M.  Colombat’s  remarks  on  the  great  dislensibility  of  the  upper  portion  of 
the  vagina.  This  fact  is  often  noticed  in  the  management  of  early  abortions, 
say  of  six  weeks  to  two  months.  In  such  cases,  when  attended  with  great 
hemorrhage,  it  is  common  to  find  the  part  of  the  tube  in  question  enor- 
mously distended,  even  when  it  does  not,  at  the  moment,  contain  but  little 
fluid  or  coagulated  blood.  The  lower  or  exterior  end  of  the  organ 
is  close,  tight  and  firm,  whereas  it  would  seem  that  the  upper  two-thirds  of 
the  canal  are  frequently  found  dilated  to  a size  sufficient  to  contain  a very 
large  pippin  or  an  orange.  I have  often  found  it  similarly  dilated  in  the 
mere  case  of  menorrhagia.  I have  so  often  had  occasion  to  find  the  parts  in 
this  state,  that  I have  little  doubt  of  its  having  been  as  frequently  observed 
by  other  practitioners,  and  it  is  important  to  dwell  upon  it  for  the  purpose 
of  indicating  the  necessity  there  is,  in  such  instances,  of  employing,  if  at  all 
employed,  a sufficiently  large  tampon.  A tampon,  consisting  of  a single 
piece  of  sponge,  is,  in  my  opinion,  inefficient,  inasmuch  as  a sponge  of 
sufficient  dimensions  to  fill  up  this  great  dilatation,  can  not  feadily  be  intro- 


OF  THE  EXTERNAL  GENITALS. 


49 


duced  through  the  os  externum.  Hence  the  tampon  that  I invariably  prefer, 
consists  of  portions  of  linen  torn  into  squares  of  three  or  four  inches,  of 
which  the  pieces  are  successively  introduced  until  the  cavity  is  quite  filled. 
Such  a tampon  very  rarely  fails  to  suppress  the  hemorrhage  of  an  early 
or  embryonal  abortion. — M.] 

We  shall  close  this  article  by  remarking,  that  there  are  frequently 
formed  in  the  vagina,  membranous  bands  or  bridles,  either  circular 
or  lateral,  which  may  interfere  with  the  operation  of  touching,  and 
prevent  us  from  getting  a view  of  the  os  uteri  on  using  the  speculum. 
Dr.  Pauly,  in  his  work  on  diseases  of  the  womb,  relates  from  Lis- 
franc,  two  cases,  in  which  that  learned  practitioner  met  with  circular 
bands  of  this  kind  dividing  the  vagina  as  by  a diaphragm,  with  a 
central  opening  of  two  or  three  lines  in  diameter,  and  situated  about 
one  inch  below  the  os  uteri.  The  uterus  was  in  a diseased  state,  as 
was  shown  by  certain  well-known  symptoms,  and  by  a considerable 
leucorrhceal  discharge.  Being  unable  to  reach  or  see  the  womb,  M. 
Lisfranc,  at  all  hazards,  resolved  to  cauterize  the  cervix  through  the 
small  opening,  and  had  the  good  fortune  to  restore  the  patient  to 
health. 

OF  THE  WOMB,  ITS  SURGICAL  RELATIONS,  AND  OF  CERTAIN  VARIE- 
TIES OF  ITS  SITUATION. 

The  womb,  which  is  designed  for  the  lodgment  of  the  foetus  from 
the  period  of  conception  until  delivery,  is  a hollow,  symmetrical 
organ,  shaped  like  a pear;  or  of  a truncated,  conoidal  figure;  placed 
in  the  pelvic  excavation,  beneath  the  convolutions  of  the  small  intes- 
tines, behind  the  bladder,  in  front  of  the  rectum,  and  attached  infe- 
riorly  to  the  vagina  ; which  is  inserted  obliquely  from  Jielow  and  in 
front,  in  a direction  upwards  and  backwards,  into  that  part  of  the 
womb  to  which  the  anatomists  have  applied  the  term  neck,  in  order 
to  distinguish  it  from  the  rest  of  the  organ  called  its  body. 

The  front  surface  of  the  womb  is  slightly  convex.  Only  the  upper 
half  of  this  part  of  the  womb  is  covered  by  the  peritoneum,  all  the 
rest  of  it  being  in  contact  with  the  bas-fond  of  the  bladder.  The 
posterior  surface,  which  is  much  more  convex  than  the  other,  is 
wholly  covered  with  the  peritoneum,  and  seems  to  be  separated  from 
the  rectum  by  a small  space  in  which  an  intestine  might  become 
strangulated. 

The  external  surface  of  the  womb  presents  three  margins  and  three 
angles.  The  superior  margin,  which  is  convex  and  smooth,  corre- 
sponds to  the  fundus ; the  two  others,  which  are  lateral  and  convex 
ill  their  superior  half,  but  concave  in  the  inferior  half,  are  covered  by 
the  broad  ligaments.  The  superior  angles  of  the  womb  are  situated 
upon  the  sides,  and  conjointly  with  the  margins,  which  are  here 
united,  they  give  rise  to  the  Fallopian  tubes,  the  ligaments  of  the 
ovaries  and  the  round  ligaments.  The  third  or  inferior  angle,  which 
it  is  most  important  to  understand  well,  forms  the  os  tincae  or  free 
extremity  of  the  uterus,  which  shall  be  described  when  we  come  to 
speak  of  this  part  of  the  womb. 

4 


50 


THE  WOMB. 


The  cavity  of  the  viscus,  of  a triangular  shape,  is  lined  by  a 
membrane,  which  we  shall  denominate  a mucous  membrane,  though 
it  has  no  epithelium;  we  denominate  it  thus  because  it  furnishes 
mucus  in  the  healthful,  and'puriform  mucus  in  the  unhealthful  state. 
The  internal  walls  of  the  womb  are  very  near  to  each  other,  and 
there  is  a raphe  along  the  median  line  of  this  cavity  both  on  the  front 
and  on  the  posterior  wall.  Upon  this  raphe  are  directed  other  oblique 
and  transverse  lines  or  folds.  In  virgins,  the  sides  as  well  as  the 
fundus  coincide  nearly  with  right  lines,  or  they  are  slightly  convex 
inwards,  whereas,  in  women  who  have  had  children,  they  are  very 
concave.  The  two  superior  internal  angles  are  continuous  with  the 
origin  of  the  Fallopian  tubes,  and  are  frequently  found  more  or  less 
dilated  like  a funnel.  The  inferior  angle,  at  the  base  of  which  is 
found  the  superior  internal  orifice  of  the  cervix,  will  soon  be  de- 
scribed in  speaking  of  the  neck  of  the  womb. 

In  women  who  have  had  no  child- 
ren, the  uterus,  from  the  top  of  the 
fundus  to  the  most  projecting  part 
of  the  anterior  lip  of  the  os  tineas, 
has,  in  most  of  our  measurements, 
been  found  to  be  from  twenty-six 
to  twenty-eight  lines  in  length ; from 
front  to  rear,  at  the  thickest  part, 
from  nine  to  eleven  lines;  and  from 
side  to  side,  measured  horizontally, 
from  twenty-three  to  twenty-four 
lines — but  it  ought  to  be  observed 
that  all  these  measurements  are  one 
or  two  lines  larger  in  women  who 
have  had  several  pregnancies.  — 
(Vide  Figure.) 

Being  retained  in  its  place  by 
very  lax  ligaments,  the  womb,  with- 
out being  itself  the  subject  of  dis- 
ease, is  readily  subject  to  displace- 
ment, and  yet  continues  to  exercise 
all  its  functions.  All  these  vari- 
ous uterine  malpositions,  of  which 
notice  will  be  hereafter  taken,  may  be  in  the  direction  downwards, 
upwards,  to  the  right,  or  the  left,  and  forwards,  or  backwards.  M. 
Lisfranc  justly  remarks  that  they  are  most  commonly  the  results  of 
uterine  engorgement,  the  weight  of  the  organ  being  augmented, 
causing  it  in  that  state  to  put  its  ligaments  on  the  stretch  and  thus  to 
lose  its  natural  position. 

The  height  of  the  womb  in  the  pelvis  may  differ  according  to  the 
stature  of  different  women,  their  climate,  or  some  peculiarity  of  con- 
stitution. Thus,  in  very  tall  women,  in  women  in  warm  latitudes, 
but  especially  in  virgins,  the  womb  is  higher  up  than  in  those  of  cold 
and  moist  countries,  in  such  as  have  had  children,  or  in  whom  the 
physical  conditions  we  have  stated  are  absent.  In  some  persons 
the  womb  is  naturally  very  low  without  any  assignable  cause,  and, 


NECK  OF  THE  WOMB. 


51 


on  the  other  hand,  it  is  often  found  to  be  very  high  up  in  the  pelvis, 
either  in  consequence  of  its  great  size,  which  gives  rise  to  a sort  of 
locking  of  the  organ  there,  or  from  the  presence  of  tumours  within 
the  pelvis,  or  even  of  faecal  matters  hardened  and  impacted  in  the 
rectum.  The  last-named  cause  sometimes  has  a different  effect — 
forcing  the  womb  down  to  the  bottom  of  the  pelvis  by  the  masses 
accumulated  above  it. 

As  the  ovaries  and  the  ligaments  of  the  womb  offer  nothing  very 
peculiar  in  regard  to  their  chirurgico-anatomical  relations,  we  shall 
proceed  to  speak  of  the  neck  of  the  womb  and  its  imperfectly  under- 
stood relations  to  the  peritoneum  and  vagina,  and,  in  fine,  all  the 
anatomical  points  on  which  are  founded  most  of  the  operations  to  be 
described  in  this  work. 

VARIETIES  OF  CONFORMATION,  AND  SURGICAL  RELATIONS  OF  THE 
NECK  OF  THE  WOMB. 

The  contracted  part  which  forms  the  inferior  angle,  I mean  the 
neck  of  the  womb,  is  extremely  variable  as  to  its  form  and  the  degree 
of  its  projection  within  the  vagina.  In  vertical  diameter  it  is  from 
eleven  to  thirteen  lines  long  in  adult  women,  and  from  eight  to  ten 
in  persons  of  advanced  years,  while  its  antero-posterior  diameter  is 
six  or  eight  lines  and  the  transverse  eight  or  ten.  On  the  extreme 
portion  of  the  neck  that  projects  into  the  vagina  there  is  a transverse 
cleft  bounded  by  two  rounded  lips— the  anterior  one  being  thicker 
and  longer  than  the  posterior,  which,  according  to  our  observations, 
is  more  frequently  than  the  other  the  seat  of  primitive  ulcerations  of 
the  os  tincae.  The  posterior  lip  is,  also,  the  one  most  frequently 
eroded  by  cancerous  ulcers,  probably  from  being  found  in  more  per- 
manent and  immediate  contact  with  all  the  secretions  of  the  womb. 
The  projection  which  these  two  lips  present  to  the  observer,  and 
which  constitutes  the  os  tincae,  is  subject  to  several  differences  in  dif- 
ferent people.  In  general  it  amounts  to  four  or  five  lines  for  the 
anterior  lip,  and  three  or  four  for  the  posterior,  although  the  con- 
trary might  be  imagined  upon  carefully  performing  the  operation  of 
touching ; for,  as  we  have  already  stated,  the  vagina  ascends  higher 
behind  than  in  front.  This  anatomical  arrangement  may  be  easily 
verified  by  separating  the  womb  completely  from  the  vagina  in  the 
subject. 

In  women  who  have  had  no  children,  the  lips  of  the  os  tincae 
are  found  shut;  but  in  those  who  have  conceived  they  are  naturally 
partly  open,  soft  internally,  and  sometimes  tubercular,  more  or  less 
tumid,  and  though  in  all  other  respects  perfectly  sound,  they  are 
occasionally  found  of  a grayish,  violaceous  or  deep-red  colour.  It  is 
easy  to  conceive  the  importance  of  not  mistaking  for  disease  all  the 
varieties  of  shape  and  appearance  we  have  described,  and  particu- 
larly the  hard  and  linear  cicatrices  which  are  the  consequence  of 
laceration  of  the  os  uteri  in  labour.  It  ought  to  be  noted,  however, 
that,  when  the  lips  of  the  os  uteri  are  uneven  and  festooned,  it  does 
not  invariably  follow,  as  is  commonly  thought,  that  there  must  have 


52 


NECK  OF  THE  WOMB. 


been  one  or  more  pregnancies,  for  certain  disorders  may  give  rise  to 
such  appearances,  and  women  who  have  conceived  again  and  again 
have  a different  condition  of  the  os  tineas. 

In  most  persons  the  neck  of  the  womb  is  not  placed  perpendicu- 
larly in  the  centre  of  the  vagina.  If  it  be  true  that  it  is  sometimes 
found  inclined  forwards,  it  nevertheless  is  almost  always  inclined 
backwards,  especially  in  married  women,  because,  during  the  copu- 
lative act,  it  is  forced  backwards  in  that  direction.  Without  being  at 
all  diseased  it  is  found  to  be  softer  and  larger  some  days  before  and 
during  the  whole  period  of  the  catamenial  discharge : it  is  then  of 
about  the  same  size,  consistence  and  sensation  as  is  found  in  it  at  the 
second  month  of  gestation. 

Our  own  anatomical  researches  have  led  us  to  conclude,  that  the 
distance  from  the  os  tincae  to  the  peritoneum  is  really  but  nine  lines 
in  front,  and  not  more  than  seven  or  eight  behind,  for  on  that  side 
the  serous  membrane  descends  quite  down  upon  the  vagina,  to  make 
the  recto-genital  excavation.  These^  measurements,  which  are  esti- 
mated to  be  greater  by  some  surgeons,  are  not  so  large  as  they  are 
in  women  advanced  in  years,  because  both  the  body  and  neck  of  the 
womb  may,  in  such  persons,  be  said  to  become  atrophied,  which  is 
doubtless  the  real  cause  of  that  obliteration  of  the  os  tineas,  long 
known  to  the  medical  authorities,  among  whom  we  may  mention 
the  names  of  Mayer  of  Bonn,  Lisfrane  and  Velpeau,  and  whieh,  in 
accordance  with  M.  Breschet’s  opinions,  we  look  upon  as  a real 
physiological  law. 

According  to  Messrs.  Velpeau  and  Civatte  de  Siteron,  the  dimen- 
sions we  have  laid  down  would  be  found  less,  particularly  behind. 
The  last  named  author,  in  his  thesis,  asserts  that  the  ant’ero-supe- 
rior  part  of  the  cervix  touches  the  bas-fond  of  the  bladder,  and 
adheres  to  it  by  means  of  a loose  layer  of  cellular  tissue,  which 
corresponds  precisely  to  the  middle  of  a line  drawn  from  the  orifice 
of  one  ureter  to  the  other.  He  adds,  that  if  a horizontal  section  of 
the  womb  should  be  made,  at  the  distance  of  four  lines  above  the 
extremity  of  the  anterior  lip  of  the  os  tincae,  it  would  just  lay  open 
the  cellular  tissue  that  unites  the  bas-fond  of  the  bladder  to  the  neck 
of  the  womb.  Instead  of  making  the  incision  at  this  point,  if  it  should 
be  effected  five  lines  above,  it  would  inevitably  open  the  peritoneum. 

M.  Civatte -says,  further,  that  in  making  an  incision  at  the  distance 
of  five  lines,  if  the  edge  of  the  bistoury  were  directed  forwards  and 
upwards,  it  must  wound  the  bladder,  particularly  if  distended  with 
urine.  Posteriorly  there  is  a greater  space  between  the  extremity  of 
the  lip  and  the  terminus  of  the  surgical  neck,  but  in  this  situation 
there  is  no  cellular  space  like  that  which  is  found  in  front,  and  a sec- 
tion, even  if  horizontal,  higher  up  than  the  limits  proposed  by  M. 
Mury,  would  hazard  a wound  of  the  peritoneum.  Here  the  rectum  is 
united  to  the  cervix  by  means  of  the  upper  part  of  the  vagina,  and 
by  about  one  line  in  width  of  cellular  tissue.  The  upper  part  of  the 
vagina  is  inserted  into  and  confounded  with  the  neck,  anteriorly,  four 
lines  above  the  end  of  the  lip,  and  posteriorly,  five  lines  higher  up 
than  the  top  of  the  posterior  lip : the  longitudinal  and  ascending 


VICIOUS  FORM  OF  THE  WOMB. 


53 


fibres  of  the  vagina  thus  proceed  to  form  the  first  muscular  layer  of 
the  cervix  uteri,  and  to  continue  upwards  with  the  superficial  longi- 
tudinal fibres  of  the  uterus. 

Before  closing  our  remarks  upon  the  subject  of  the  cervix  uteri,  it 
ought  to  be  observed  that  the  degree  of  its  projection  into  the 
vagina  is  not  always  as  great  as  we  have  stated,  for  its  varieties  are 
infinite.  Women  in  phthisis,  for  example,  have  the  neck  of  the 
womb  remarkably  prominent;  in  little  girls,  nine  or  ten  years  of  age, 
as  is  the  case  with  the  clitoris,  the  salience  of  the  cervix  is  pro- 
portionably  greater  than  it.  is  in  adult  women.  In  the  latter  it  often 
loses  in  length,  but  gains  in  breadth  or  thickness.  In  aged  persons, 
on  the  contrary,  it  disappears  almost  completely,  and  always  seems 
to  become  absolutely  atrophied. — (Vide  figure,  which  needs  no  ex- 
planation.) 

Fig.  2. 


FAULTY  CONFORMATION,  PRIMITIVE  OR  ACCIDENTAL,  OF  THE 
FEMALE  SEXUAL  ORGANS. 

The  sexual  organs  of  females  are  subject  to  vices  of  form,  consist- 
ing in  their  absence,  occlusion,  narrowness,  adherence,  voluminous- 
ness, connections  and  shape.  The  greater  part  of  these  lesions 
depend  upon  some  fault,  arrest  or  aberration  in  the  laws  of  their 
development,  or  on  some  disease'  affecting  the  individual  either  be- 
fore or  after  her  birth. 

The  records  of  the  science  contain  no  sample  of  complete  and 
simultaneous  absence  of  all  the  internal  genital  organs.  In  some 
rare  cases  only  a single  ovary  has  been  found,  with  one  tube,  and 
half  of  a womb.  There  may  be  absence  of  the  ovaries,  while  all  the 
other  sexual  organs  are  in  a natural  condition. 

In  a post-mortem  examination,  carefully  conducted,  M.  Jadelot 
found  but  a single  ovary.  They  have  been  by  various  persons  met 
with,  of  very  minute  size,  which  almost  invariably  implies  sterility, 


54 


VICIOUS  FORM  OF  THE  WOMB. 


for  the  Graafian  vesicles  could  not  be  developed  in  such  ovaria. 
The  Fallopian  tubes  have  been  found  to  have  contracted  adhesions 
with  the  peritoneum,  or  to  be  closed  in  a few  instances,  in  some  near 
the  ovary,  in  others  near  to  the  womb. 

Theden,  Lieutaud,  Bousquet,  Engel,  Professor  Caillot,  MM.  Re- 
nauldin,  Breschet  and  others,  have  related  cases  of  absence  of  the 
womb,  and  have  found  examples  in  which  the  neck  alone  existed, 
and  others  in  which  it  remained  in  the  rudimental  state. 

The  womb  has  also  been  found  divided  into  two  equal  or  unequal 
portions,  either  entirely  or  partially,  internally  or  externally,  and  that 
in  the  same  case.  Such  a case  constitutes  what  is  called  a double 
uterus,  or  two-horned  uterus,  like  the  natural  uterus  of  a quadruped. 

It  may  likewise  be  perfectly 
divided  into  two  separate 
wombs,  each  of  them  opening 
by  an  os  uteri  into  a separate 
vagina.  Or  they  may  have  a 
single  cervix,  though  the  body 
is  divided  into  two  distinct 
halves.  There  are  cases  met 
with,  in  which  the  exterior 
shape  of  the  womb  is  not  at  all 
changed  from  the  natural  ap- 
pearance, yet  its  cavity  is  di- 
vided into  two  parts  by  a ver- 
tical median  septum. 

It  has  happened,  but  very  rarely,  indeed,  that  the  womb  has  been 
so  very  little  developed,  as  to  nullify,  physiologically  speaking,  its 
entire  functions.  Baron  Portal,  in  his  Pathological  Anatomy , 
speaks  of  two  women  in  whom  the  womb  was  not  in  either  of  them 
larger  than  it  is  in  a child  of  nine  or  ten  years  old.  They  were  both 
moderately  fat,  the  mons  veneris  was  not  covered  with  hair,  and  the 
other  external  genitals  presented  the  same  characters  as  are  observ- 
able in  childhood.  M.  Renauldin  also  tells  us  of  a woman  who, 
instead  of  a womb,  exhibited  a cord  about  the  size  of  a writing  quill, 
while  M.  Pauly  cites  the  example  of  a lady  of  sixteen  years  old,  not 
yet  regular,  and  subject  from  her  ninth  year  to  attacks  of  hysteria,  in 
whom  he  found  a womb  the  size  of  a hazelnut,  with  a bulb  not 
three  lines  in  diameter. 

Although,  in  most  cases,  the  orifices  of  the  bilobate  womb  open 
with  a simple  or  double  vagina,  it  is  shown  by  Valisnieri,  Saisard 
and  Daverney  that  one  of  them  sometimes  opens  into  the  rectum, 
while  the  other  preserves  its  true  position.  But  whether  the  os  tincae 
be  single  or  double,  whether  it  depend  upon  a bilobate  or  natural 
womb,  it  has  not  very  unfrequently  been  met  with  opening  into  the 
rectum,  the  bladder,  or  the  urethra,  or  even  above  the  symphysis  of 
the  pubis. 

The  womb  is,  also,  the  subject  of  other  anomalies  of  shape  ; for 
example,  the  neck  or  body  is  obliterated  wholly  or  in  part,  in  conse- 
quence either  of  a primary  organic  vice  or  of  an  accident.  Bichat, 
Lallemant,  Leroux  of  Dijon,  Buisson,  Gardien,  M.  Lisfranc  and 


Fig.  3. 


VICIOUS  FORM  OF  THE  WOMB  AND  VAGINA. 


55 


other  authors  have  proved,  as  we  have  ourselves  done,  that  the 
cervix  may,  in  some  persons,  acquire  a very  considerable  length  and 
volume,  and  that  sometimes,  on  the  contrary,  it  is  so  small  that  its 
substitute  seems  to  be  a mere  tubercle.  Its  position  may,  likewise, 
exhibit  variations  from  the  natural  order  of  things,  and  it  may  be 
deranged  by  adhesions  which  tie  one  of  its  surfaces  or  sides  too  near 
the  brim  of  the  pelvis. 

Specimens  of  faulty  conformations  of  the  vagina  are  as  frequently 
met  with  as  those  of  the  womb.  It  may  be  wholly  or  partly  wanting. 
The  external  orifice  may  be  closed  by  a membrane  that  prevents  the 
escape  of  the  menses  at  the  age  of  puberty,  and  gives  rise  to  the 
most  serious  consequences.  It  may  be  absent  as  to  its  upper  or 
middle  portion,  and  not  communicate  with  the  womb.  It  has  been 
seen  to  open  into  the  rectum.  But  this  deformity,  which  is  always 
complicated  with  imperforation  of  the  vulva,  does  not  compromise 
the  person  affected  with  it,  and  it  generally  remains  undiscovered  till 
the  menstrual  discharge,  taking  place  into  the  rectum,  causes  its  ex- 
istence to  be  discovered.  In  his  Treatise  on  Midwifery,  Barbaut, 
formerly  king’s  surgeon  at  the  Chatelet,  has  given  the  history  of  a girl 
who  conceived  by  this  passage,  and  was  brought  to  bed  without  any 
other  accident  than  the  rupture  of  the  sphincter-ani  muscle. 

In  certain  equally  rare  cases  the  vagina  may  open  into  the  bladder, 
or  into  the  bladder  and  rectum  at  the  same  time.  This  sort  of 
anomaly,  which,  as  well  as  the  one  last  mentioned,  is  beyond  the  re- 
sources of  the  art,  compromises  the  patient’s  life,  and,  like  it,  is  rarely 
discovered  until  the  menstrual  period  of  life,  when  a monthly  dis- 
charge from  the  bladder  leads  to  a suspicion  of  the  real  nature  of  the 
case.  It  is  quite  a difficult  task  to  avoid  confounding  it  with  the 
sanguineous  exhalation  from  the  interior  lining  of  the  urinary  blad- 
der, which  is  sometimes  observed  to  take  place  as  vicarious  to  the 
catamenial  office  of  the  womb  in  instances  of  absence  of  the  uterus. 

In  some  specimens  the  vagina  has  been  found  completely  divided 
by  a median  longitudinal  septum,  directed  vertically  from  before 
backwards ; but,  in  such  a state  of  things,  the  womb  is,  also,  for  the 
most  part,  found  to  be  bilobate.  Lastly,  the  canal,  which  may  be 
wholly  wanting  in  the  subject,  is  found  extremely  narrow  and  short, 
and  both  of  these  anomalies  may  be  either  co-existent  or  not. 

The  clitoris,  the  labia  and  the  nymphm,  either  individually  or  all 
alike,  do,  in  certain  cases,  acquire  enormous  size,  or  the  external  geni- 
tals may  be  wholly  wanting,  or  may  be  coherent  either  by  a single 
point  of  contact  or  throughout. 

If  the  absence  of  the  womb,  the  tubes  and  the  ovaries,  involves 
the  consequence  of  barrenness,  the  absence  of  the  vagina,  its  want 
of  due  length,  its  constriction  and  narrowness,  are  also  in  the  way 
of  the  sexual  union.  Imperforation  of  the  exterior  orifice  of  the 
canal  and  cohesion  of  the  labia  may  occasion  serious  consequences 
as  to  the  discharge  of  the  menses. 

[[I  do  not  perceive  any  foundation  for  the  fear  expressed  by  M.  Colombat 
of  the  obturator  power  of  coherent  labia,  because,  in  all  possible  cases  of  such 


56 


SYMPATHIES  OF  THE  WOMB. 


cohesion,  there  must  remain  an  exitus  for  the  urine,  which,  as  it  escapes 
from  beneath  the  triangular  ligament  of  the  pubis,  it  will  always  keep  the 
labia  from  cohering  to  the  troublesome  extent  supposed  by  the  author. — M.3 

The  double  cavity  of  the  vagina, 
the  tube,  being  divided  by  a me- 
dian septum  corresponding  with  a 
bilobate  uterus  divided,  each  form 
into  a distinct  cavity,  and,  duly 
provided  with  its  appendages, might 
consist  with  the  possibility  of  a su- 
perfcetation  which,  without  such 
anomalous  form,  seems  difficult  to 
explain. 

Adhesion  of  the  neck  of  the 
womb  to  the  vagina,  as  well  as 
its  occlusion,  almost  in  every  case 
prevents  conception;  and  adhesions  of  the  Fallopian  tubes  and  the 
ovaries  to  the  peritoneum  also  promote  the  formation  of  extra-uterine 
pregnancy,  but  much  more  commonly  lead  to  barrenness.  Lastly, 
any  unnatural  opening  of  the  womb  into  the  rectum,  openings  of  the 
rectum  into  the  vagina,  and  those  of  the  vagina  into  the  bladder, 
afford  very  reasonable  explanations  of  certain  anomalies  observable 
in  females,  whether  as  regards  the  discharge  of  the  catamenia,  the 
emission  of  the  urine,  or  the  dejection  of  the  alvine  products. 

Inasmuch  as  the  congenital  deformities  of  the  female  sexual  organs 
are  so  numerous  and  varied,  and  as  the  principal  part  of  them  do  not 
involve  her  life  in  any  danger,  we  believe  that  we  have  spoken  suffi- 
ciently in  extenso  upon  the  subject,  the  more  especially  as  we  shall, 
in  the  course  of  this  work,  have  occasion  to  speak  of  them  in  greater 
detail,  and  to  point  out  the  surgical  processes  appropriate  to  most  of 
them. 

OF  THE  SYMPATHIES  OF  THE  WOMB. 

In  physiology  and  therapeutics  we  understand  by  the  word  sym - 
pathiesf the  relations  of  two  or  more  organs,  more  or  less  near  to  or 
remote  from  each  other,  which  have  established  betwixt  them  an 
association,  by  means  of  which  the  vitality  of  the  one  is  modified  by 
that  of  the  other,  whether  that  vitality  be  in  a sound  or  in  an  un- 
healthful  state.  There  is  nothing  more  certain  than  is  the  existence 
of  a bond  of  sympathy  which  communicates  certain  modifications  of 
the  vital  state  to  one  or  several  remote  organs,  from  an  impression 
received  by  some  other  organ.  These  modifications  that  are  parti- 
cipated in  by  the  intermediate  parts,  cannot  be  referred  to  the  mere 
mechanical  connection  or  to  the  common  alliance  of  functions;  but 
they  appear  to  depend  upon  a certain  peculiar  organization,  which 
causes  all  those  parts  to  vibrate  in  unison,  that  are  so  arranged  as  to 
irradiate,  of  themselves,  the  impressions  they  receive,  whether  di- 
rectly by  nervous  anastomosis,  or  indirectly  by  the  intervention  of  the 
brain.  In  explaining  the  sympathies  of  the  womb  with  most  of  these 
organs,  we  shall  restrict  ourselves  to  the  statement  of  facts,  without 


Fig.  4. 


SYMPATHIES  OF  THE  WOMB. 


57 


going  into  an  examination  of  their  causes,  since  they  are  covered 
with  a veil  as  impenetrable  as  that  which  conceals  from  us  the  real 
nature  of  the  nervous  power. 

The  ancients,  who  were  ignorant  of  the  sympathies  of  the  uterus 
with  other  parts  of  the  body,  supposed  that  it  was  endowed  with  a 
special  existence,  and  a temperament  independent  of  the  general 
constitution.  They  thought  that  the  body,  properly  speaking,  should 
be  regarded  merely  as  a cage,  within  which  the  uterus  enjoyed  the 
faculty  of  moving  in  any  direction,  and  of  affecting  any  organ  to 
which  it  might  proceed,  while  the  latter  could  not  exert  upon  it  the 
smallest  influence. 

Among  others,  Plato  says,  “ that  the  womb  is  a wild  beast  that 
obeys  no  reason,  but  which,  when  its  desires  are  unsated,  wanders 
about  within  the  body  and  excites  all  sort  of  irregular  motions.” — 
( Tim.  500.) 

The  sympathetic  phenomena  of  the  womb,  resulting  from  the  or- 
ganization of  the  female,  are  so  evident,  that  it  would  be  worse  than 
absurd  to  call  them  in  question.  It  is,  therefore,  indispensable,  espe- 
cially for  the  physician  who,  in  his  practice,  is  chiefly  conversant  with 
the  diseases  of  women,  to  have,  as  far  as  possible,  the  most  exact 
information  as  to  the  intimate  relation  of  the  uterus  with  the  other 
organs,  and  with  the  reaction  of  these  latter  upon  it.  This  study  is 
of  the  highest  importance,  since  the  life  of  the  patient  may  depend 
upon  it.  In  fact,  it  sometimes  happens  that  the  only  clue  to  a suspi- 
cion of  uterine  disease  is  to  be  found  in  the  sympathetic  phenomena. 
In  all  such  cases  that  physician  alone  can  make  a sure  diagnosis,  and 
order  a rational  method,  who  possesses  a perfect  knowledge  of  the 
sympathetic  irradiations  of  the  womb. 

It  has  happened  that  ulcerations  or  engorgements  of  the  cervix, 
or  even  confirmed  cancers  of  the  organ,  have  been  treated  as  cases 
of  chronic  gastro-enteritis,  because  they  exhibited  many  symptoms 
of  these  disorders,  which  were  in  reality  nothing  more  than  sympa- 
thetic affections,  results  of  the  abnormal  and  pathological  reaction  of 
the  womb  upon  them.  It  is  generally  not  until  they  have  had  fre- 
quent and  considerable  haemorrhage,  and  severe  pain  in  the  sexual 
organs,  that  women  make  up  their  minds  to  consult  a more  eminent 
medical  man,  who  then,  but  often  too  late,  learns  the  sad  certainty  of 
the  nature  of  the  case. 

Many  distinguished  physicians,  M.  Lisfranc  among  others,  have 
been  consulted  for  diseases  supposed  to  be  nephritis,  gastralgia,  gas- 
tritis, enteritis,  palpitation,  active  aneurism  of  the  left  ventricle,  lum- 
bago, sciatic  or  crural  neuralgia,  &c.,  which  were,  in  reality,  but  the 
sympathetic  reaction,  and  the  symptoms  of  a disease  of  the  womb, 
that  might  be  perfectly  made  known  by  touching,  by  the  use  of  the 
speculum,  and  especially  by  the  disappearance  of  all  the  nervous 
phenomena,  in  consequence  of  the  treatment  and  cure  of  the  uterine 
affection. 

We  have  ourselves  been  often  consulted  for  eases  of  aphonia,  pro- 
duced by  a sympathetic  action  of  the  womb,  excited  by  a physical 
or  physiological  lesion  of  the  organ.  As  in  aphonias  of  this  sort, 


58 


SYMPATHIES  OF  THE  WOMB. 


several  cases  of  which  are  related  in  our  treatise  on  diseases  of  the 
vocal  organs,  the  larynx  is  generally  found  to  be  perfectly  healthy  in 
its  appearance,  it  is  only  by  a knowledge  of  the  uterine  sympathies 
that  we  are  enabled  to  suspect  and  detect  the  cause,  and  the  true  seat 
of  the  malady.  For  the  establishment  of  a good  diagnosis  in  all 
these  difficult  circumstances,  it  is  indispensable  for  us  to  know  the 
nearly  invariable  connection  that  exists  between  certain  kinds  of  pain 
and  the  affections  of  the  uterine  system.  Instead  of  the  sympathetic 
irradiations  of  the  organ  we  are  liable  to  combat  only  the  symptoms, 
and  not  the  disease  that  gives  rise  to  them ; and  frequently  allow,  in 
spite  of  all  the  therapeutical  resources  of  the  art,  a disease  to  become 
aggravated  up  to  an  incurable  stage. 

The  sympathies  and  the  connection  that  exist  betwixt  the  womb 
and  all  the  other  organs,  may  be  made  manifest  by  the  following 
described  phenomena. 

1.  With  the  breasts:  we  shall  prove  it  by  the  decided  coincidence 
observed  at  puberty  in  their  growth,  in  the  development  of  the  geni- 
tal organs,  and  the  first  eruption  of  the  menses. 

No  one  is  ignorant  of  the  fact,  that  the  sucking  and  titillation  of 
the  nipple  by  the  young  child  is  sometimes  accompanied  by  sensa- 
tions referred  to  the  reproductive  organs.  Hippocrates  was  the  first 
to  notice  the  fact  that  the  breasts  of  the  pregnant  woman  become 
flaccid,  when  the  foetus  dies,  or  during  a uterine  haemorrhage;  or 
that  the  suppression  of  the  menses  and  of  the  lochia,  or  the  distension 
of  the  womb  by  a mole,  a polypus,  by  hydatids  or  any  other  foreign 
body,  whose  expulsion  is  effected  by  the  contractions  of  the  womb, 
are  apt  to  produce  a secretion  of  milk,  and  a full  milk  fever,  like  that 
which  follows  an  ordinary  parturition. 

Women  who  give  suck,  and  have  an  abundance  of  milk,  are  not 
commonly  regular,  have  but  little  lochia,  and  are  rarely  subject  to 
leucorrhoea,  whereas  those  who  lose  their  milk,  and  thus  only  half 
fulfil  the  obligations  of  the  mother,  are  liable  to  the  whites,  to  abun- 
dant lochial  discharges,  as  well  as  copious  menstrual  effusions. 

2.  The  sympathy  of  the  womb  with  the  stomach  is  rendered  suffi- 
ciently manifest,  by  the  qualms,  the  strange  appetite,  the  nausea  and 
vomiting,  and  by  certain  hysterical  affections  observable  in  some 
pregnant  persons,  and  in  others  who  have  irregular  menses,  or  some 
disease  seated  in  the  womb  itself. 

Its  influence  upon  the  stomach  has  been  acknowledged  by  almost 
all  the  authors,  and  in  particular  by  Rega,  where,  in  his  brilliant  dis- 
sertation De  Sympathia,  p.  137,  he  says:  Ergo  si  ab  utero  labo - 
rante , plura  stomacho  contingcmt  incommoda  non  est  dubitan- 
dum  quin  ventriculo  patiente  pati  debeat  et  uterus. 

The  active  sympathies  of  the  womb  upon  the  stomach  commonly 
disappear  about  midway  of  the  term  of  gestation,  because  the  organ 
is  at  that  period  occupied  with  its  own  condition,  and  has  no  longer 
any  excess  of  vital  activity  to  infuse  into  other  portions  of  the  viscera. 

3.  The  sympathy  with  the  brain  is  perfectly  evident.  Do  we  not 
find  that  pregnant  women,  on  the  one  hand,  lose  their  memory,  or, 
•on  the>o.ther,  have  it  greatly  strengthened;  that  their  imagination  is 


SYMPATHIES  OF  THE  WOMB. 


59 


much  more  lively,  or  that  they  become  less  intelligent ; that  they 
exhibit  symptoms  of  insanity,  that  they  wish  to  bite  persons  whom 
they  really  love,  are  prompted  to  homicidal  acts,  lose  their  reason, 
become  maniacs,  cruel,  thievish,  &c.  &c.? 

Has  it  not  often  happened  that  a violent  fit  of  passion,  a jealousy, 
a sudden  fright,  a violent  impression  on  the  mind,  have  arrested  the 
flow  of  the  menses  or  lochia,  and  suspended  the  secretion  of  milk, 
or  at  least  changed  the  nature  of  the  liquid,  while  the  whites  are 
increased  by  vexation  or  great  distress  of  mind. 

4.  The  cessation  of  a uterine  catarrh,  and  the  appearance  of  a 
bronchial  catarrh ; the  disappearance  of  the  latter  following  the  ap- 
pearance of  the  former  ; the  dyspnoea,  syncope,  palpitation,  oppres- 
sion, spitting  of  blood,  and,  in  short,  a number  of  phenomena  of  this 
sort  noticed  in  pregnancy,  and  during  the  existence  of  many  uterine 
disorders,  sufficiently  prove  the  intimate  connection  between  this 
viscus  and  the  respiratory  organs. 

The  change  in  the  voice  at  puberty  and  at  the  close  of  the  menses  ; 
the  aphonia  and  dysphonia  sometimes  met  with  in  pregnancy,  and 
under  some  affections  of  the  womb;  the  sensation  often  excited  in  the 
genitalia  when  a child  or  a lover  imprints  a kiss  upon  the  lips,  or 
merely  touches  any  part  of  the  body;  the  indigestion,  borborygmi, 
colic,  cephalalgia,  toothache,  tinnitus  of  the  ears,  and  other  symp- 
toms supervening  at  different  stages  of  pregnancy ; the  tumefaction 
of  the  belly  before  menstruation ; the  spontaneous  vomiting  and  all 
the  nervous  phenomena  that  follow  rupture  of  the  womb  in  labour, 
or  an  operation  performed  on  the  organ  ; the  cessation  of  an  obsti- 
nate uterine  catarrh  from  the  application  of  a blister,  or  an  issue  to 
the  arm  ; the  suppression  of  uterine  hasmorrhage  by  the  application 
of  a sinapism,  or  cup  under  the  breasts,  or  the  immersion  of  the 
hands  or  feet  in  cold  water ; the  energy  imparted  to  the  womb  in 
labour  by  the  inhalation  of  acetic  acid,  by  frictions  with  alcoholic 
liquors,  or  the  application  of  cold  to  the  belly;  and  a variety  of  other 
phenomena,  both  physiological  and  pathological,  compose  a group  of 
proofs  capable  of  establishing  the  reality  of  the  sympathies  and  con- 
nections that  exist  betwixt  the  womb  and  all  the  other  organs,* 
and  prove  the  accuracy  of  these  two  aphorisms  of  Van  Helmont — 
Propter  solum  uterum,mulier  id  est  quod  est...femina  omnem  bis 
patitur  morbem. 

An  attempt  here  to  explain  the  causes  of  the  great  influence  of  the 
womb  upon  the  entire  economy,  would  be  to  enter  a labyrinth  of 
theories  easier  to  imagine  than  to  unravel.  Any  researches  made  in 

* Those  of  our  readers  who  may  desire  fuller  and  more  curious  views  of  the  sen- 
sibility of  the  womb,  would  do  well  to  consult  the  works  of  Haller,  Walter,  Wm. 
Hunter,  and  especially  the  important  work  of  Fred.  Tiedemann,  published  in  Heidel- 
burg  in  1822,  under  the  title  of  Tabulae  Nervorum  Uteri , fol.  He  has  endeavoured 
to  exhibit  an  anatomical  demonstration  of  the  manifest  connections  of  the  uterine 
nerves  with  the  great  ganglionic  and  encephalic  system  of  nerves,  in  order  to 
explain  the  sympathetic  irradiations  and  the  different  consensus  noted,  whether  during 
menstruation,  conception,  pregnancy,  labour  or  suckling;  whether  in  the  physical 
and  vital  lesions  of  the  uterus,  in  the  hysterical  affections  and  other  troubles  to  which 
women  are  liable. 


60 


TOUCHING,  AND  THE  SPECULUM. 


this  direction  would  certainly  tend  only  to  prove  still  more  conclu- 
sively, that  man  may  ever  seek  in  vain  to  lift  up  the  veil  that  shrouds 
the  impenetrable  secrets  of  nature. 


CHAPTER  III. 


EXAMINATION  OF  THE  FEMALE  ORGANS  OF  GENERATION,  BT  TOUCHING  AND  BT  THE 

SPECULUM. 

OF  TOUCHING  PER  VAGINAM. 

The  operation  of  touching  is  not  so  easy  a matter  as  one  might  at 
first  suppose  ; and  it  requires  long  practice  and  repeated  trials,  both 
upon  the  dead  subject  and  upon  living  persons,  to  acquire  the  readi- 
ness that  is  desirable  in  discriminating  between  the  various  lesions 
that  are  found  upon  the  interior  genitalia. 

As  most  modern  writers,  and  the  general  treatises  upon  surgery, 
are  wholly  silent  on  this  most  important  point  in  the  diagnosis  of 
sexual  disorders,  we  conceive  it  will  not  be  out  of  place  to  indicate 
the  rules  to  be  followed  in  touching,  and  the  different  modes  of  per- 
forming that  operation. 

The  bladder  and  rectum  having  been  emptied,  the  patient  should 
lie  across  the  bed  with  a pillow  under  her  head  thick  enough  to 
raise  it  a little  higher  than  her  hips.  She  should  place  herself  so 
that  the  coccyx  should  project  a few  inches  over  the  edge  of  the 
mattrass,  while  the  feet  rest  upon  two  chairs  about  a foot  apart.  The 
operator,  seated  upon  one  of  the  chairs,  carefully  introduces  the  index 
finger,  anointed  with  oil  or  dipped  in  mucilage,  into  the  vagina, 
directing  it  backwards  and  somewhat  upwards.  The  preparation 
of  the  finger  and  a gently  rotary  movement,  render  its  introduction 
easier  to  him  and  less  painful  to  the  patient.  If  seated  upon  her 
right  side,  he  should  touch  with  his  right  hand,  and  vice  versd. 
Care  should  be  taken  to  pare  the  nail,  lest  the  vagina  might  be  hurt 
by  it.  He  might,  also,  if  on  any  account  preferable,  place  the  patient 
lengthways  in  bed,  in  a dorsal  position,  the  head  and  shoulders 
slightly  raised,  the  feet  drawn  up  near  the  body  and  resting  on  the 
mattrass,  the  knees  moderately  separated,  so  as  to  afford  no  obstruc- 
tion to  the  operator’s  hand.  To  render  the  womb  more  accessible, 
and  the  introduction  of  the  finger  easier,  and  to  avoid  unnecessary 
awkwardness,  the  pelvis  should  be  raised,  either  by  the  woman  ele- 
vating it  at  his  request,  or  by  placing  under  it  a cushion  or  a pillow. 
Every  thing  being  arranged  as  now  directed,  he  will  place  himself 
by  that  edge  of  the  bed  nearest  to  which  the  patient  lies,  and  then 
turning  himself  towards  her,  let  him  pass  his  hand  under  her  dress 
and  betwixt  the  knees.  Then  let  the  operation  be  concluded  as 
above  directed.  This  mode  of  effecting  the  touch  is  particularly 


TOUCHING. 


61 


applicable  to  cases  in  which  it  is  necessary  to  examine  the  region  of 
the  hypogastrium  by  palpation. 

There  is  a third  method,  which  we  prefer  to  the  two  now  described, 
whether  because  it  enables  us  to  judge  better  of  the  weight,  size, 
direction  and  elevation  of  the  womb,  or  because  it  is  less  alarming 
to  the  delicate  feelings  of  a person  subjected  for  the  first  time  to  this 
trial.  This  method  consists  in  placing  her  standing  with  her  back 
against  a partition,  with  her  feet  properly  separated,  and  allowing 
her  muscles  to  be  as  relaxed  as  possible.  The  surgeon  kneeling  on 
one  knee,  and  pressing  one  hand  on  the  hypogaster  to  force  the 
uterus  downwards,  introduces  the  index,  anointed  with  oil,  upwards 
and  backwards  into  the  vagina,  until  he  reaches  the  os  tincae,  which, 
if  natural,  feels  like  a circular,  firm  and  resisting  ring,  and  giving 
rise  to  a sensation,  as  the  elder  Dubois  judiciously  observes,  very 
much  like  that  one  experiences  when  touching  the  tip  of  the  nose 
betwixt  the  cartilages. 

After  having  fully  examined  the  vagina,  the  operator  should  pro- 
ceed to  examine  the  cervix  uteri  as  to  its  temperature,  its  form,  its 
situation,  the  dilatation  of  its  orifice,  its  sensibility,  its  volume,  its 
consistence,  and  lastly,  he  should  ascertain  whether  there  be  any 
ulceration  of  it,  any  erosions*  or  fissures,  roughness,  exuberance, 
excrescences,  vegetations,  haemorrhoids,  varices,  or  any  polypus  occu- 
pying the  whole  or  a portion  of  its  circumference.  He  ought  to  be 
careful  not  to  mistake  for  actual  disease,  the  rents  often  met  with  in 
women  who  have  had  children ; such  solutions  of  continuity  are 
nothing  more  than  the  consequences  of  those  lacerations,  to  which 
the  neck  of  the  womb  is  liable  during  labour. 

Having  well  examined  the  os  tincae,  the  operator  ought  to  try,  by 
pressing  the  finger  as  far  as  possible  upwards  betwixt  the  cervix  and 
the  surrounding  parts,  to  ascertain  the  state  of  its  surface.  This 
information  is  best  obtained  by  touching  first  with  the  one  and  then 
with  the  other  hand,  as,  indeed,  ought  always  to  be  done.  The  right 
hand  explores  the  right  side  of  the  vagina,  and  the  left  side  of  the 
cervix,  while  the  left  hand  operates  in  the  inverse  direction,  and 
explores  the  opposite  sides.  When  the  state  of  ail  the  parts  has 
been  sufficiently  understood,  and  the  successive  steps  of  the  inquiry 
carefully  remembered,  the  hand  should  be  removed  as  gently  and 
speedily  as  possible,  in  order  to  avoid  fatiguing  the  woman.  The 
index  should  be  seen  for  the  purpose  of  learning  whether  it  is  stained 
with  blood,  a sign  of  organic  lesion,  provided  the  patient  is  not  actu- 
ally under  her  catamenial  period.  And  lastly,  for  the  purpose  of 
more  surely  knowing  the  nature  and  colour  of  the  blood  and  other 
humours  brought  away  by  the  hand,  it  should  be  wiped  with  a nap- 
kin before  washing  the  hands. 

In  a case  where  we  are  chiefly  to  examine  the  lower  and  anterior 
part  of  the  vagina,  the  woman  ought  to  be  in  a horizontal  position, 
resting  upon  her  knees  and  her  hands.  The  position  may  be  changed 
by  requesting  her  to  lie  upon  either  side,  as  may  be  considered  de- 
sirable, and  according  to  the  regions  to  be  subjected  to  the  inquiry 


62 


TOUCHING  BY  THE  RECTUM. 


or  the  attitude  that  would  be  most  likely  to  bring  the  deviated  womb 
into  a more  favourable  situation. 

Although  the  touch  is  applicable  to  the  vast  majority  of  cases,  cir- 
cumstances arise  that  render  it  necessary  to  defer  it,  and  even  wholly 
to  reject  this  excellent  mode  of  exploring  disease.  Thus,  we  should 
avoid  touching  for  several  days  before  and  after  the  menstrual  term, 
and  more  especially  during  their  flowing,  because  the  womb,  at  that 
time,  undergoes  changes  that  might  lead  to  erroneous  conclusions. 
Touching  ought  not  to  be  done  either  when  the  patient  is  subjected 
to  severe  pains,  nor  when  the  vagina  is  highly  sensitive  and  irritated 
by  the  slightest  friction.  In  such  a case  we  should  imitate  the  practice 
of  M.  Lisfranc,  by  curing  this  unnatural  irritation  by  means  of  small 
bleedings  at  the  arm  to  act  as  revulsives,  and  by  the  prolonged  use 
of  the  bath,  and  by  the  semicupium  and  small  anodyne  injections. 
In  fine,  we  ought  to  abstain  from  touching,  or  rather  not  repeat  it, 
when  we  are  sure  that  the  malady  is  incurable,  as  we  may  know  to 
be  the  case  when  we  find  the  uterus  large,  botryoidal,  and  with  a 
neck  affected  with  vegetations,  lacerations  and  holes  that  bleed  at 
the  slightest  touch,  and  yield  a noisome  stench  characteristic  of  the 
carcinomatous  affections.  All  further  search  in  such  cases  would  be 
as  useless  as  dangerous,  for,  in  these  desperate  cases,  each  examina- 
tion increases,  and  that  without  the  least  prospect  of  usefulness,  the 
patient’s  sufferings,  and  often  becomes  the  cause  of  a violent  inflam- 
mation or  a fatal  haemorrhage. 

Although,  as  a general  rule,  we  ought  to  examine  early,  we  ought 
to  recur  to  it  as  seldom  as  possible,  and  only  in  case  of  absolute  neces- 
sity, and  then  always  observing  the  utmost  caution.  This  precept 
will  not,  however,  be  carried  so  far  out  as  to  deprive  the  attendant 
of  all  information  required  to  note  the  progress  of  the  disease,  and 
the  changes  that  may  demand  some  modification  of  the  therapeutical 
treatment.  It  is  especially  in  the  treatment  of  sexual  disorders  that 
the  physician  should  endeavour  to  inspire  the  greatest  confidence,  for 
females  submit  to  touching  not  without  the  greatest  repugnance,  and 
only  when  pressed  by  sufferings  characterized  by  increasing  violence. 

OF  TOUCHING  BY  THE  RECTUM. 

Having  completed  the  operation  of  touching  per  vaginam,  should 
there  be  any  remaining  doubts  as  to  the  state  of  the  womb  and  its 
appendages,  and  especially  if  any  operation  is  about  to  be  performed 
upon  the  parts  contained  within  the  cavity  of  the  pelvis,  the  physi- 
cian has  within  his  power  another  excellent  mode  of  exploration — 
one  which  throws  a great  deal  of  light  upon  the  diagnosis  of  the  dis- 
eases of  women,  and  which  is  even  better  adapted  than  the  vaginal 
touch  for  the  investigation  of  the  excavation  and  the  organs  contain- 
ed within  it.  We  allude  to  the  mediate  touch  through  the  rectum, 
which  ought  not  to  be  resorted  to,  however,  when  it  becomes  difficult 
on  account  of  the  presence  of  painful  hmmorrhoidal  tumours,  spas- 
modic constriction  of  the  sphincters,  or,  lastly,  from  certain  diseases 
of  the  anus  or  the  bowel.  It  is  proper,  however,  to  say  that  even 


TOUCHING  AT  THE  HYPOGASTRIUM. 


63 


in  the  most  difficult  cases,  when  the  examination  by  the  rectum  had 
been  supposed  in  some  sort  impossible  and  completely  contra-indi- 
cated, we  have  always  been  enabled  to  effect  it  with  sufficient  facility 
and  without  producing  much  pain.  This  we  have  brought  about 
by  introducing  into  the  anus,  an  hour  or  two  before  the  operation,  a 
suppository  of  beurre  de  cacao  with  which  had  been  incorporated 
half  a grain  of  extract  of  opium  and  the  same  quantity  of  extract  of 
belladonna. 

But  where  there  is  no  obstacle  to  the  introduction  of  the  index, 
the  bowel  having  been  first  emptied  by  means  of  an  enema,  we 
proceed  as  in  the  vaginal  examination,  but  more  gently,  so  as  better 
to  overcome  the  resistance  of  the  sphincters.  Without  this  precau- 
tion the  patient  often  suffers  from  a sort  of  constriction  and  a painful 
tenesmus  that  will  not  admit  of  the  operation  being  long  continued. 

One  thing  ought  not  to  be  lost  sight  of:  I mean  that  we  should 
follow  the  curve  of  the  rectum  until  the  index  has  reached  the  sacro- 
vertebral  angle ; care  should  also  be  taken  to  place  one  hand  on  the 
hypogastrium,  for  the  purpose  of  pressing  the  bladder  down  upon  the 
pubis  and  the  womb  towards  the  lower  part  of  the  pelvis.  By  this 
mode  we  are  enabled  not  only  to  examine  the  state  of  the  back  part 
of  the  womb,  but  even  to  learn  the  state  of  the  broad  ligaments,  the 
ovaries,  the  tubes,  and,  in  fact,  to  ascertain,  when  it  is  not  to  be  found 
in  the  excavation,  the  existence  of  some  pathological  lesion,  some 
carcinomatous  mass,  contra-indicating  any  operation  which,  in  such 
circumstances,  could  by  no  means  save  the  patient’s  life.  An  exam- 
ple of  this  sort  we  witnessed  in  a patient  at  La  Pitie,  on  whom  M. 
Lisfranc  had  operated  for  amputation  of  the  neck  of  the  womb, 
eighteen  days  before.  The  dissection  disclosed  a carcinomatous  mass, 
which  embraced  the  lumbar  portion  of  the  vertebral  column  and 
contained  some  encephaloid  matter. 

The  touch  by  the  rectum  is  the  best  means  of  investigation  for 
the  volume  and  the  obliquities  of  the  womb,  where  this  organ  does 
not  rise  above  the  symphysis  of  the  pubis.  It  is  also  the  best  mode 
of  ascertaining  the  existence  or  absence  of  the  womb  in  cases  of 
imperforation  or  total  absence  of  the  vagina. 

OF  PALPATION  ABOVE  THE  PUBIS,  OR  TOUCHING  AT  THE  HYPO- 
GASTRIUM. 

If  it  be  desirable  to  inquire  into  the  condition  of  all  the  exterior 
surfaces  of  the  womb,  there  yet  remains  to  be  performed  the  sur- 
pubal  or  hypogastric  touch,  which  is  effected  by  placing  the  patient 
on  her  back,  the  head  supported,  the  shoulders  slightly  raised,  the 
thighs  flexed,  and  the  feet  resting  upon  the  mattrass,  so  as  to  allow 
to  the  abdominal  muscles  the  greatest  possible  relaxation.  Except 
when  absolutely  necessary  to  examine  the  uncovered  surface,  the 
chemise  should  be  the  only  part  of  the  dress  left  to  conceal  her  skin. 
The  operator’s  open  hand  should  be  placed  upon  the  hypogastrium, 
at  first  transversely  and  then  vertically,  so  as  to  press  the  abdominal 
parietes,  and,  by  gentle  movements  in  a transverse  direction,  should 


64 


THE  SPECULUM. 


be  made  to  push  the  bladder  downwards  and  the  bowels  upwards, 
so  as  to  reach  at  last  the  womb  itself,  which  is  felt  to  be  a solid  and 
movable  body.  With  the  tips  of  the  fingers  the  womb  can  now  be 
examined  on  its  anterior  surface  and  a knowledge  obtained  of  its 
volume,  shape,  consistence,  mobility,  and  its  connections  with  the 
surrounding  parts;  and,  lastly,  by  examining  also  the  iliac  fossa  we 
can  determine  whether  the  tubes  and  ovaries  are  diseased,  as  by 
tumour  or  other  malady  not  otherwise  to  be  ascertained. 

In  order  to  obtain  the  utmost  certainty  in  the  diagnosis  of  the  sex- 
ual disorders,  and  to  prevent  the  mistakes  and  dispel  the  doubts  to 
which  the  similarity  of  their  symptoms,  notwithstanding  the  great 
differences  in  their  real  nature,  might  give  occasion,  we  must  not 
rest  contented  with  the  operation  of  touching  alone,  though  we  ought 
always  to  begin  by  that.  It  is  necessary,  on  many  occasions,  to  add 
to  this  excellent  means  of  exploration,  the  use  of  the  speculum  uteri , 
which  allows  us  to  judge  of  the  malady  by  inspection,  and  yields  an 
almost  mathematical  certainty  as  to  the  determination  of  its  nature. 
It  is  by  the  aid  of  this  instrument  that  we  are  enabled  rigorously  to 
appreciate  the  volume,  shape,  colour  and  appearance  of  the  affected 
parts,  and  thus  being  in  full  possession  of  the  facts  as  to  the  actual 
situation  and  existence  of  certain  lesions,  inappreciable  by  the  touch, 
we  are  naturally  in  the  right  track  as  to  those  therapeutical  indica- 
tions whose  efficacy  is  established  on  the  grounds  of  experience. 

OF  THE  SPECULUM  UTERI  AND  THE  MANNER  OF  USING  IT. 

If  we  meet  with  much  difficulty  in  persuading  the  patient  to  sub- 
mit to  the  operation  of  touching,  it  is  easy  to  conceive  what  care  is 
necessary  to  render  as  little  distressing  as  possible,  the  sacrifice  that 
a modest  woman  makes  on  the  score  of  delicacy,  when  she  is  led  to 
expose  to  the  physician  parts  that  she  always  conceals  with  the 
greatest  care. 

In  cases  where  the  external  genitalia  are  to  be  examined,  the 
patient  should  lie  across  the  bed,  or  be  seated  in  an  easy  chair  or  on 
a sofa,  with  the  knees  well  separated,  and  raised  upwards  in  the 
former  case  by  two  chairs,  and  in  the  latter  by  pillows.  The  surgeon 
being  before  her,  kneeling  on  one  knee,  will  examine,  in  the  first 
place,  the  perineum  and  the  labia,  then  separating  them,  he  will  ascer- 
tain the  state  of  the  mucous  surface,  the  clitoris,  the  vestibule,  the 
nymphae,  the  orifice  of  the  urethra,  the  anterior  and  inferior  portions 
of  the  vagina,  and,  in  fine,  all  the  folds  of  the  vulva,  which  may 
conceal  small  ulcers  that  it  is  important  that  he  should  discover. 

If  it  should  seem  desirable  to  subject  not  only  the  vagina,  but  also 
the  neck  of  the  womb  to  the  same  scrutiny,  it  will  be  found,  as  before 
remarked,  indispensable  to  make  use  of  the  speculum  iiteri,  by 
means  of  which  the  walls  of  the  vagina  may  be  separated,  and  the 
os  tineas  itself  brought  into  view. 

This  vaginal  dilater,  to  which  so  unfit  a name  has  been  given,  and 
which  we  should  prefer  to  call  a hysteroscopc , were  it  not  that  we 
fear  the  imputation  of  being  neologists,  has  been  subject,  since  its 


SPECULUM  UTERI. 


65 


introduction  into  practice,  to  numerous  changes,  an  historical  sketch 
of  which  we  propose  to  give,  before  pointing  out  the  method  of 
applying  it. 

The  invention  of  the  speculum  is  of  the  highest  antiquity,  and  it 
would  be  difficult  to  give  the  name  of  its  inventor,  or  the  period  at 
which  it  was  first  made  use  of.  According  to  Aetius,*  Archigenes, 
of  Apamea,  in  Syria,  who  settled  in  Rome  under  the  reign  of  Domi- 
tian,  was  the  first  to  make  known  the  instrument  in  question.  In 
a translation  of  Paulus  iEginetta  by  Rondelet,  the  author,  in  the 
article  phyrnosis  in  females,  says,  U instrument  appelle  8<,o7tspa,eslant 
introduit  fermeb  dedans  la  vulue , apres  soil  lourn£  pour  Pouvrir , 
affin  que  les  conjunctions  du-dit  instrument  soient  eslargies , et  la 
cauiti  de  la  feme  soil  distendue.  t The  speculum  that  Paulus  iBgi- 
nettaf  speaks  of  was  composed  of  two  branches  that  were  made  to 
act  by  means  of  a screw.  Avicenna,!  who  died  about  A.  D.  1036, 
who  had  received  the  title  of  Prince  of  Physicians,  and  who,  by  the 
Arabs,  was  considered  a second  Galen,  and  Albucasis,§  who  died 
A.  D.  1122,  have  described,  under  the  title  of  vertigo , two  kinds  of 
speculum  uteri , with  three  branches,  that  were  made  to  separate 
from  and  approach  each  other  by  means  of  a screw  handle.  These 
instruments  are  figured  in  the  work  of  Andreas  de  la  Croce. ||  Spa- 
chius,1[  the  author  of  a collection  of  writers  on  diseases  of  women ; 
Franco,**  who  first  performed  lithotomy  by  the  high  operation; 
Pare, ft  Scultetus,!!  Garengeot,§§  and  several  other  authors  of  the  last 
century,  have  likewise  published  different  sorts  of  jointed  speculum, 
with  two  or  three  branches  ; but  these  instruments,  which  were  for 
the  most  part  inconvenient,  had  fallen  into  disuse,  when  Professor 
Recamier  revived  the  use  of  them  by  demonstrating  their  utility  in 
the  exploration  of  the  genital  organs.  The  instrument  that  was 
first  used  by  that  excellent  practitioner  was  extremely  simple,  and 
consisted  of  a tin  tube,  the  uterine  extremity  of  which  presented  a 
circumference  with  rounded  edges,  which  admitted  of  its  embracing 
the  neck  of  the  womb,  without  risk  of  injuring  it.  The  instrument, 
which  was  too  long,  and  conical,  and  beveled  at  its  vulvar  extre- 
mity, was  modified  by  M.  Dupuytren,  who  shortened  it  to  the  length 
of  the  vagina,  and  added  a handle,  by  means  of  which  it  could  be 
more  firmly  held  and  more  readily  introduced.  Professor  A.  Dubois, 
for  the  purpose  of  adopting  it  to  the  exploration  and  treatment  of 
vaginal  fistulas,  added  a notch  or  slit  near  its  superior  extremity. 

Since  that  time  the  speculum  has  been  modified  by  Madame  Boi- 
vin,  Messrs.  Lisfranc,  Weis,  Deyber,  Ricque,  Guillon,  Bertze,  Joubert, 
Thompson,  Ricord,  and  especially  by  M.  Charriere,  the  distinguished 
cutler  of  Paris,  who  has  invented  several  different  kinds,  of  which 
we  shall  have  occasion  to  speak  in  the  course  of  this  work,  and  of 

# Lib.  iv.  cap.  86.  f Lib.  iii.  cap.  66.  * Tract,  iv.  cap.  3. 

§ Lib.  ii.  cap.  77.  ||  Officina  Chirurgica,  p.  39.  ^ Gynaeciorum,  1597. 

**  Traite  des  Hernies,  &c.,  et  autres  Maladies,  &c.,  1651. 

ff  Les  (Euvres  d’Ambroise  Pare,  Liv.  xxiv.  chap.  86.  Paris,  1585. 

44  Armamentar  Chir.,  Tab.  xl.  p.  153.  Ven.  1668. 

§§  Nouveau  Traite  des  Instruments  de  Chirurg.,  tom.  i.  pi.  28.  Paris,  1723. 

5 


66 


SPECULUM  UTERI. 


which,  as  well  as  of  the  other,  we  shall  give  a description  and  figures 
in  our  Diet.  Histor.,  et  Iconographique  of  all  the  chirurgical  instru- 
ments and  operations. 

In  our  memoir  on  amputation  of  the  neck  of  the  womb,  published 
in  1828,  we  gave  a description  and  figure  of  a speculum  with  six 
and  eight  branches,  which  we  had  invented  in  1827,  and  which  we 
again  represent  in  this  work.  This  instrument,  of  a conical  shape, 


Fig.  5.  Fig.  6. 


with  the  base  at  the  handle  when  closed,  and  at  the  other  extremity 
when  opened,  may  be  introduced  when  of  a small  size,  and  opens 
only  near  the  os  uteri,  when  it  abundantly  separates  the  parietes  of 
the  vagina,  so  as  to  afford  space  to  act  freely  where  some  operation  is 
required.  To  use  the  instrument,  it  must  first  be  fitted  with  its  end- 
piece,  which  is  of  an  oval  shape.  This  end-piece,  which  is  of  steel, 
polished  like  the  rest  of  the  speculum,  whose  cone  it  completes, 
receives  the  branches  of  the  instrument  in  its  concavity,  which  facili- 
tates its  introduction  and  obviates  the  pain  which  the  inequalities  of 
the  point  of  the  speculum  might  otherwise  produce. 

When  the  speculum  has  passed  through  the  vulva,  and  is  suffi- 
ciently deep  within  the  vagina,  the  end-piece  is  disengaged  by 
pushing  it  a little  forwards  by  the  handle,  and  is  then  withdrawn 
by  slightly  opening  the  instrument  so  as  to  give  it  room  to  pass  out 
easily.  The  instrument  may  be  opened  by  turning  the  screw  which 
pulls  the  ring  towards  the  immovable  base  of  the  cone  formed  by 
the  shut  speculum.  Having  laid  the  end-piece  aside,  the  speculum 
is  completely  introduced,  opening  the  branches  gradually  as  it  goes 
forward. 

This  speculum  is  particularly  convenient  in  effecting  the  excision 
of  the  cervix  uteri,  because  in  every  one  of  its  diameters  it  produces 


SPECULUM  UTERI. 


67 


Fisr.  7. 


great  dilatation  .only  near  the  womb,  which  greatly  facilitates  the 
operation  by  the  methods  which  we  shall  explain.  M.  Velpeau  does 
not  do  justice  to  it  in  saying  that  it  is  apt  to  pinch  the  vaginal  mu- 
cous membrane,  for  it  is  so  formed  that  such  an  accident  can  by  no 
means  happen. 

In  cases  where  a simple  exploration  is  required,  we  make  use  of 
M.  Recamier’s  speculum  instead  of  our  own, 
above  described.  It  consists  of  a conoidal  tube 
of  tin  or  silver,  to  which  I have  added  a han- 
dle, with  a joint  an  inchin  length,  and  turning 
backwards  towards  the  body  of  the  instru- 
ment. The  speculum  thus  modified  is  very 
convenient  and  portable.  To  a great  sim- 
plicity of  construction  it  joins  the  advantage 
of  being  easy  of  application,  and  of  showing 
better  than  other  instruments  the  cervix  by 
reflecting  the  light  upon  it.  Besides,  as  it  is 
whole,  the  mucous  membrane  of  the  vagina 
cannot  mask  the  os  uteri,  as  in  other  appli- 
ances it  is  said  to  do,  by  intruding  itself  be- 
twixt the  open  branches  of  other  speculums 
composed  of  several  pieces.  Such  a difficulty, 
which  really  does  not  exist,  since  the  vagina  is  stretched  when  the 
speculum  is  in  situ , would  readily  disappear  by  giving  to  the  instru- 
ment a few  slight  rotary  motions,  first  in  one  direction  and  then  in 
the  other. 

But  whatever  kind  of  speculum  it  may  be  that  is  to  be  used,  the 
following  rules  ought  to  be  observed  in  order  to  proceed  properly  to 
its  application.  The  patient  should  lie  upon  her  back  across  the  bed, 
with  the  hips  near  the  edge  of  it,  her  feet  being  supported  upon  two 
chairs,  the  thighs  widely  separated.  The  pelvis,  somewhat  higher 
than  the  head,  should  be  firmly  supported,  and  should  project  a little 
beyond  the  margin  of  the  mattrass.  Every  thing  being  thus  pre- 
pared, let  the  surgeon  proceed  to  introduce  the  speculum,  after  having 
warmed  it  a little  and  anointed  it  with  oil  or  mucilage  to  render  its 
insertion  easier  and  less  painful  to  the  patient.  Then,  having  sepa- 
rated the  labia  externa  and  interna  with  the  thumb  and  index  of  the 
left  hand,  let  him  direct  the  point  of  the  instrument  to  the  orifice  of 
the  vagina,  holding  it  so  as  to  make  with  the  canal  an  obtuse  angle 
posteriorly.  With  gentle  efforts  and  slight  rotary  motion  the  specu- 
lum, which  ought  to  bear  most  upon  the  posterior  wall  of  the  vagina, 
will  readily  pass  upwards  to  the  os  tineas,  pushing  before  it  the  mu- 
cous membrane  which  forms  a sort  of  circular  cushion  or  fold  that 
very  much  resembles  the  neck  of  the  womb.  He  must  take  care 
not  to  mistake  it  as  such,  a^d  be  cautious  in  inserting  the  speculum 
gently,  so  as  not  to  bruise  the  parts  he  wishes  to  examine. 

When  the  os  uteri  has  been  brought  into  view,  care  should  be 
taken  not  to  press  it  backwards,  because,  in  that  case,  the  body  of 
the  womb  would  take  a position  as  in  a kind  of  anteversion,  which 
would  render  it  impossible  to  examine  the  os  tincae ; and  the  farther 


68 


SPECULUM  UTERI. 


the  speculum  should  be  pushed  the  more  difficult-would  it  become 
to  examine  the  parts — and  this  is  the  reason  why  it  has  been  rejected 
and  abandoned  by  several  surgeons  as  a useless  instrument — the  fact 
being  that  they  did  not  understand  the  use  of  it. 

For  the  purpose  of  correcting  the  position  of  the  cervix  and  com- 
pelling it  to  project  within  the  end  of  the  speculum,  we  invented 

a kind  of  concave  lever,  by 
Fig.  8.  means  of  which  the  os  tincae 

can  be  drawn  forwards.  This 
instrument,  which  is  more  easy 
of  application  than  Madame 
Boivin’s  fenestral  spoon,  which  is  too  broad,  has,  at  the  other  end  of 
it,  a forceps  with  a slide  for  the  purpose  of  holding  a bit  of  sponge, 
a portion  of  charpie  or  a linen  tampon,  either  to  cleanse  or  cauterize 
the  os  tincae  according  as  the  indication  may  be. 

Having  reached  the  bottom  of  the  vagina,  in  order  to  increase  the 
saliency  of  the  cervix  the  patient  should  be  told  to  bear  down,  with 
expulsive  efforts  as  if  on  the  close  stool. 
When  the  cervix  is  perfectly  exposed,  it 
should  be  cleansed  with  a bit  of  sponge  or 
some  parcels  of  lint  fixed  in  the  forceps  of 
our  lever,  or  upon  our  four-branched  for- 
ceps ; all  the  mucus  that  has  been  pressed 
upwards  about  the  os  uteri  ought  to  be  care- 
fully removed,  to  admit  of  a perfect  inspec- 
tion. This  is  obtained  by  the  light  of  a taper 
placed  betwixt  the  orifice  of  the  vagina  and 
a metallic  mirror,  which  we  invented  and 
denominated  the  hysteroscope , and  which 
throws  an  abundant  light  to  the  very  bot- 
tom of  the  speculum.  The  rays  of  the  taper, 
being  reflected  from  the  mirror,  form  a luminous  cone  by  their  con- 
vergence, the  apex  of  which  falls  upon  the  neck  of  the  womb.  In 
this  way  we  may  make  sure  of  a perfect  exploration  of  the  diseased 
organ,  and  of  discovering  certain  alterations  which,  but  for  the  re- 
flection, could  never  be  ascertained. 

It  ought  here  to  be  remarked  that  the  choice  of  the  metal  for  the 
speculum  is  not  a matter  of  indifference.  Those  of  silver,  tin  or 
polished  steel  are  to  be  preferred.  It  is  especially  advisable  to  avoid 
such  as  are  composed  of  two  metals,  as,  for  example,  the  plated  ones, 
for  we  have  observed  that  the  use  of  such  was  painful,  because  the 
contact  of  two  metals  and  the  acid  mucus  of  the  vagina  give  rise  to 
certain  voltaic  phenomena  that  were  capable  of  a considerable  reac- 
tion upon  the  womb. 

But,  whatsoever  be  the  nature  of  the  speculum,  the  use  of  it  should 
always  be  governed  by  the  rules  above  laid  down,  observing  always 
that  the  handle  should  be  upwards,  lest  it  might  give  trouble  by 
catching  against  the  bed-clothes  if  turned  in  a downward  direction. 

Although  the  utility  of  the  speculum  is  incontestable  for  a great 
many  kinds  of  cases,  there  are,  as  in  the  operation  of  touching,  some 


Fig.  9. 


SPECULUM  UTERI. 


69 


circumstances  that  ought  to  induce  us  to  defer  or  even  wholly  to 
reject  it.  For  example,  cases  of  acute  inflammation  of  the  vagina; 
contractions  of  the  passage  in  elderly  persons  and  in  young  virgins; 
membranous  bands  across  the  vagina;  the  hymen;  and  all  the  reasons 
for  deferring  the  touch  are  equally  applicable  against  the  employ- 
ment of  the  speculum,  until  all  the  counter-indications  have  been 
removed  by  proper  precautions  or  operations. 

The  instrument  should  be  absolutely  prohibited  in  all  cases  of 
deep  ulceration  of  the  cervix  and  vagina,  as  endangering  the  pro- 
duction of  serious  lacerations  and  haemorrhages.  It  is  also  useless, 
and  even  dangerous,  where,  by  the  touch,  the  existence  of  extensive 
carcinomatous  vegetations,  or  a large  fungus  of  the  cervix  has  been 
ascertained.  Lastly,  in  all  cases,  before  proceeding  to  the  examina- 
tion of  the  internal  genitalia,  the  rectum  should  be  emptied  by  means 
of  an  enema,  for  the  purpose  of  getting  rid  of  all  extraneous  obsta- 
cles or  sources  of  error  in  the  examination. 

Notwithstanding  the  use  of  the  speculum  is  always,  at  least  for 
respectable  women,  a serious  sacrifice  of  their  delicacy,  such  a con- 
sideration ought  not  to  arrest  the  medical  adviser,  when  he  has  rea- 
son to  suspect  the  existence  of  some  lesion,  whether  actual  or  only 
threatening  to  become  serious.  He  ought,  therefore,  to  insist  upon 
his  purpose,  and  endeavour  to  persuade  them  to  submit  to  the  exami- 
nation, though  so  repugnant  to  their  feelings.  It  is  in  such  cases  that 
he  ought  to  inspire  the  greatest  confidence,  and  by  gentleness  and 
good  conduct,  so  perform  the  operation,  as  to  lessen,  as  far  as  practi- 
cable, the  moral  and  physical  distress  that  are  the  ordinary  accom- 
paniments of  these  inquiries. 

We  shall  not  close  this  chapter  without  remarking  that  among 
the  different  means  of  exploring  the  uterus,  reliance  is  placed  upon 
the  stethoscope,  which  Fodere,  Major,  and  especially  Kergaradec, 
have  proposed  for  the  auscultation  of  the  foetal  pulsations,  and  to 
discriminate  thus  betwixt  pregnancy  and  a variety  of  disorders  that 
occasion  enlargement  of  the  womb,  such  as  dropsy,  tympanitis,  &c., 
of  the  organ.  The  instrument  which  we  have  rendered  more  con- 
venient and  portable,  by  constructing  it  with  tubes  that  slide  one 
within  the  other,  like  a spy-glass,  ought  to  be  applied  betwixt  the 
anterior  margin  of  the  pelvis  and  the  level  of  the  umbilicus,  being 
placed  higher  as  the  pregnancy  is  more  advanced.  The  patient 
should  be  examined  while  lying  down. 

The  foetal  heart,  which  sounds  at  each  pulsation,  beats  100, 140  or 
150  times  a minute,  while  the  mother’s  heart  beats  only  from  sixty 
to  seventy-five  times.  These  sounds  are  the  certain  signs,  not  only 
of  pregnancy,  but  of  the  life  and  health  of  the  foetus  ; the  latter  being 
judged  of  by  the  force  and  frequency  of  the  beats.  Foetal  pulsations, 
very  manifestly  perceived,  yet  coinciding  with  very  little  develop- 
ment of  the  womb  itself,  would  be  in  proof  of  the  existence  of  extra- 
uterine  pregnancy.  However,  the  absence  of  the  pulsations  like 
that  of  the  active  and  passive  motions  of  the  child,  are  not  conclusive 
proofs  as  to  the  life  of  the  child,  or  even  the  fact  of  gestation.  As 
the  employment  of  the  stethoscope,  in  this  case,  is  to  be  looked  upon 


70 


SPECULUM  UTERI. 


rather  as  an  obstetrical  than  as  a medico-chirurgical  exploration,  we 
may  properly  dispense  with  more  extended  observations  upon  it, 
merely  adding  that  the  metroscope  proposed  by  M.  Nauche,  for 
hearing  the  sounds  and  appreciating  the  movements  that  are  to  be 
distinguished  in  the  vagina  and  womb,  is,  in  our  opinion,  a much  less 
trustworthy  means  than  the  stethoscope,  properly  so  called. 

[M.  Colombat  appears  to  me  to  have  passed  very  hastily  over  his  remarks 
upon  auscultation  as  an  obstetrical  resource,  and  it  seems  barely  justice  to  the 
reader  and  to  a distinguished  gentleman,  Dr.  Evory  Kennedy,  of  Dublin,  to 
mention  his  work  on  the  signs  of  pregnancy,  a little  volume  that  has  added 
much  to  the  facility  of  acting  with  prudence  as  well  as  knowledge  in  cer- 
tain doubtful  cases.  The  use  of  the  stethoscope,  or  of  immediate  ausculta- 
tion, is  become  a resource  of  the  most  indispensable  kind  in  the  conduct  of 
labours,  and  in  settling  questions  of  pregnancy.  It  is  not  to  be  doubted 
that  the  use  of  the  stethoscope  may,  in  some  cases  at  least,  enable  us  to 
detect  the  sensible  signs  of  pregnancy,  if  the  child  be  alive,  as  early  as  the 
end  of  the  fourth  month  of  gestation.  By  its  use,  also,  we  may  be  very 
correctly  determined  as  to  our  course  of  action,  since  it  reveals  with  clearness 
the  state  of  the  child’s  circulation.  Now,  if  we  find  that  the  pulsations  of 
the  child  in  utero  are  becoming  dangerously  disordered,  either  by  excessive 
precipitation  of  the  heart’s  action,  or  extreme  feebleness,  irregularity  or 
slowness  of  the  same,  it  is  manifest  that  we  have  possession  of  the  means 
of  deciding  whether  the  security  of  the  infant  demands  our  intervention,  in 
the  way  of  some  obstetrical  operation,  as  the  use  of  the  forceps,  &c.  So, 
also,  where,  in  a bad  labour,  we  have  repeatedly  recognized  the  situation  and 
activity  of  the  foetal  heart,  if  upon  carefully  seeking  in  vain  for  them  in  the 
same  place,  it  being  impossible  for  them  to  have  changed  their  place,  we 
have  the  elements  of  an  opinion  as  to  some  operation  of  cephalotomy,  &c., 
which  we  might  have  been  highly  inclined  to  perform,  but  from  our  respect 
to  the  rights  of  the  foetus — rights  which  cease  with  the  cessation  of  its  life. 
Doubtless,  also,  by  means  of  auscultation,  we  may  gain  great  light  as  to  the 
diagnosis  of  position,  to  the  saving  for  the  patient  much  of  that  distress  or 
pain  that  an  exploration  with  the  wrhole  hand  could  not  fail  to  give;  an 
exploration  now  often  unnecessary,  by  the  gentler  intervention  of  auscultation. 

In  the  diagnosis  of  pregnancy  from  dropsy,  and  various  other  forms  of 
disease,  which,  by  their  exterior  physiognomy,  so  closely  simulate  several 
stages  of  gestation,  the  methods  by  auscultation  are  invaluable.  M.] 


CAUSES  or  DISEASES  OF  FEMALES. 


71 


CHAPTER  IV. 


GENERAL  CAUSES  AND  SYNOPTICAL  TABLE  OF  DISEASES  OF  FEMALES. 

It  would  be  easy  to  explain  why  the  sexual  organs  of  the  female 
are  more  subject  to  disease  than  those  of  men,  by  reflecting  that  her 
share  in  the  act  of  reproduction,  which  is  vastly  greater  than  that  of 
the  male,  imposes  upon  her  organs  of  generation  a most  painful  func- 
tion, and  that  in  her  the  different  parts  of  the  reproductive  functions 
are  numerous  and  protracted. 

There  are  a variety  of  circumstances  to  be  regarded  as  deviations 
from  the  design  of  nature,  and  which  are  the  most  ordinary  causes 
of  various  genital  affections.  Among  them  we  may  cite  the  state  of 
celibacy,  continence,  abusus  coitus , the  too  frequent  provoking  of 
erotic  spasms,  sterility,  laborious  labours,  abortions,  drying  up  the 
milk,  &c.  If  it  be  true  that,  in  the  higher  classes  of  society,  and 
especially  in  the  great  capitals,  we  meet  with  a greater  number  and 
variety  of  the  diseases  of  females  than  in  country  places  and  amongst 
the  less  exalted  ranks,  it  is  doubtless  owing  to  the  latter  being  less 
under  the  influence  of  the  perturbing  causes  which  accumulate  in 
and  are  perpetually  renewed  as  to  the  females  who  live  in  a state  of 
opulence. 

As  the  womb  is  an  organ  upon  which  most  of  the  impressions, 
both  physical  and  moral,  made  in  the  female,  are  reflected,  we  ought 
to  count  among  the  most  common  causes  of  uterine  diseases  in  great 
capitals,  particularly  at  Paris,  the  insalubrious  nature  of  the  air,  dis- 
regard of  the  laws  of  hygieine,  protracted  vigils,  cold  and  astringent 
cosmetic  lotions  for  the  vulva  during  or  soon  after  the  menses,  the  use 
of  foot  warmers,  the  abundance  of  exciting  dishes,  the  immoderate 
use  of  ices  and  sherbet,  and  of  coffee ; great  political  excitement  and 
commotions,  secret  manoeuvres,  illicit  enjoyments,  the  distracting  and 
oft-repeated  emotions  excited  by  theatrical  representations  and  the 
reading  of  works  of  fiction;  jealousy,  disappointed  love,  loss  of  for- 
tune, domestic  chagrin,  joy  too  strongly  felt,  frequent  fits  of  passion; 
and,  in  a word,  all  the  violent  passions  and  every  species  of  mental 
shock. 

It  is  easy  to  perceive  how  all  these  causes  must  be  more  powerful 
in  their  pernicious  influence  among  city  women,  and  especially  those 
of  the  elevated  class,  because,  as  they  are  in  general  more  nervous, 
more  impressionable,  and  endowed  with  the  liveliest  imagination, 
they  are,  by  that  very  circumstance,  most  prompt  to  take  the  alarm, 
on  account  of  their  own  families,  and  sometimes  on  account  of  persons 
who  are  strangers  to  them.  The  consequence  of  their  social  position 
and  the  modifications  resulting  from  their  habits  and  manners,  ren- 


72 


CAUSES  OF  DISEASES  OF  FEMALES. 


der  their  sensibility  and  delicacy  very  frequent  causes  of  grief  and 
distress. 

In  country  women  and  among  the  common  people  the  affections 
of  the  sexual  organs  often  depend  upon  totally  different  causes.  For 
example,  a residence  in  marshy  countries,  a damp  and  badly-lighted 
dwelling-house,  violent  bodily  exertion,  blows,  falls  upon  the  buttocks, 
atmospherical  vicissitudes,  cold  feet,  the  continued  use  of  coarse  food 
and  alcoholic  drinks ; sitting  on  the  grass  or  on  the  ground,  or  a stone 
bench,  immersion  of  the  hands  or  feet  in  cold  water;  the  use  of 
emmenagogues  taken  with  criminal  design ; meddlesome  midwifery, 
continued  employment  at  sedentary  labour  in  cellars,  or  in  low  damp 
workshops,  lifting  heavy  weights  or  carrying  heavy  burthens  for  a 
long  time  for  sale  in  town ; finally,  rage,  libertinism,  drunkenness, 
filthiness  and  a variety  of  other  causes,  both  physical  and  moral,  too 
tedious  to  mention  here. 

The  change  of  life  is  also  a frequent  source  of  sexual  disorders, 
inasmuch  as  the  cessation  of  the  menstrual  discharge  determines 
towards  the  pelvis  a congestion  giving  rise  to  uterine  haemorrhage 
and  organic  alterations  which  tend  to  become  very  serious  when  left 
to  themselves.  It  is  at  this  period  of  life  that  we  may,  with  Horace, 
say: — 

Multa  ferunt  anni  venientes  comraoda  secum, 

Multa  recedentes  adimunt. 

The  first  effect  of  disease  of  the  womb  is  to  produce  a prompt 
reaction  upon  both  the  physical  and  the  moral  nature  of  the  female. 
She  becomes  sad,  melancholy,  restless  and  susceptible,  and  troubled 
with  sinister  presentiments.  Those  who  live  in  a state  of  opu- 
lence withdraw  from  society,  or  rush  into  the  vortex  of  company,  as 
if  to  escape  from  an  evil  that  they  fear  without  understanding  it,  and 
which,  from  a sentiment  of  false  delicacy,  they  permit  to  become  so 
aggravated  that  it  unhappily,  too  often,  gets  beyond  the  reach  of 
art.  Those  particularly  who  are  attacked  with  carcinoma  of  the 
cervix  uteri  soon  find  that  their  beauty  and  freshness  are  gone,  and 
that  the  malady,  which  increases  pari  passu  with  their  sufferings, 
both  wrinkles  and  fades  them 

Comme  un  fruit  dont  le  coeur  est  rouge  par  un  ver. 

From  this  succinct  enumeration  of  the  general  causes  of  female 
diseases  we  should  gather  the  notion  of  how  much  prudence  and 
sagacity  are  required  in  governing  the  health  of  an  organization  so 
delicate  and  so  mobile,  and  into  what  depths  of  the  heart  the  physi- 
cian ought  to  seek  and  detect  the  principle  of  so  many  unnatural 
shocks,  so  as  to  put  in  motion  the  springs  of  a sensibility  as  inconstant 
as  it  is  flexible. 

In  order  to  facilitate  the  study  of  the  lesions  of  the  genitalia,  and  to 
group  them,  as  far  as  practicable,  according  to  the  natural  order  they 
ought  to  occupy  in  a general  system  of  pathology,  of  which  they 
constitute  but  a trifling  portion,  we  have  made  a classification  in 
which  we  divide  them  into  six  sections: — as,  1.  Lesions  of  form  and 
development,  2.  Lesions  of  situation.  3.  Physical  lesions . 4. 


VICIOUS  CONFORMATION  OF  GENITALS, 


73 


Vital  lesions.  5.  Lesions  of  functions.  6.  Lesions  appertaining 
to  reproduction . 

Although  we  might  be  disposed  to  look  upon  this  classification  of 
female  diseases  as  more  rational  than  those  proposed  by  our  prede- 
cessors, we  are  far  from  deeming  it  perfect  and  unattackable.  But  we 
are  somewhat  reassured,  in  regard  to  its  imperfections,  by  the  con- 
sideration that  there  is  no  perfect  classification  in  pathology;  and 
further,  that  all  writers  on  female  disorders  have,  like  ourselves,  met 
with  some  shoals  which  it  is  impossible  to  avoid. 


I.  Section-. 

Lesions  of 
Form  and 
Development. 


II.  Section. 

Lesions  of 
Situation. 


III.  Section. 

Physical 

Lesions. 


IV.  Section. 
Vital  Lesions. 


V.  Section. 

Lesions  of 
Functions. 


Synopsis  of  the  Diseases  of  Females. 


Comprising  all  cases  of  vicious  conformation,  whether  congenital  or 
accidental,  of  the  sexual  organs  and  their  appendages — among  which 
we  enumerate  absence  of  the  labia,  cohesion  of  the  labia,  excessive 
magnitude  of  the  nymphae,  cohesion  of  the  nymphse,  excessive  deve- 
lopment of  the  clitoris,  imperforation  and  stricture  of  the  urethra, 
< absence  of  the  vagina,  contraction  of  the  vagina,  narrowness  of  the 
vagina,  obliteration  of  the  vagina,  imperforation  of  the  vagina,  obtu- 
ration of  the  vagina,  congenital  opening  of  the  vagina  into  the  rectum 
or  bladder,  absence  of  the  womb,  bifid  womb,  incomplete  develop- 
ment of  the  womb,  congenital  occlusion  of  its  neck  and  its  accidental 
^obliteration,  and,  lastly,  imperforation  of  the  Fallopian  tubes. 


Comprising  all  cases  of  displacement,  and  deviation  of  the  geniio-uri- 
nary  organs  of  the  female — among  which  we  arrange  hysteroptosis  or 
prolapsus  of  the  womb;  anteversion,  retroversion,  anteflexion,  retro- 
I flexion,  inversion,  obliquity,  elevation  and  immobility  of  this  organ ; 
j hysterocele  and  all  the  hernias  of  the  womb  and  ovaries;  vaginal 
cystocele  and  enterocele ; vulvar  enterocele  and  cystocele ; prolapsus 
of  the  urethral  mucous  membrane;  prolapsus  of  the  lining  membrane 
^of  the  vagina,  and  invagination  of  the  canal. 

f Comprising  all  cases  of  lesion  of  continuity,  and  the  accidental  intro- 
| duction  of  foreign  bodies — among  which  are  found  wounds,  contusions 
J and  lacerations  of  the  vulva,  the  fourchette,  the  vagina,  the  uterus, 
] and  the  rupture  of  the  womb;  vesico-vaginal,  urethro- vaginal  and 
| recto-vaginal  fistula;  and,  lastly,  foreign  bodies  accidentally  intro- 
kduced  into  the  genital  cavities. 


f Comprising  the  phlegmasia,  the  transformations,  and  all  the  patho- 
logical products  and  degenerations  of  texture,  such  as  phlegmon,  carci- 
noma, oedema,  cysts,  varix,  fibrous  and  sanguine  tumours  of  the 
labia.  Inflammation  and  fungus  of  the  nymphas,  carcinoma  of  the 
clitoris  and  meatus  urinarius,  erysipelas,  prurigo,  venereal  chancres 
and  syphilitic  excrescences  of  the  vulva,  acute  vaginitis,  chronic 
vaginitis,  and  all  the  white  discharges;  acute  and  chronic  metritis, 
uterine  phlebitis,  ulceration,  excoriation,  fungous  tumours  and  en- 
gorgement of  the  cervix  uteri;  scirrhus,  cancer,  carcinoma,  putre- 
scence, softening,  dropsy  and  tympanitis  of  the  womb;  metrorrhagia, 
polypus,  fibrous  tumours,  calculus,  hydatids,  sanguine  and  lymphatic 
concretions  formed  in  the  cavity  or  in  the  substance  of  the  womb ; 
scirrhus,  cancer,  encysted  tumours,  and  dropsy  of  the  ovary;  and 
^lastly,  cancer  of  the  breast. 


Comprising  the  neuroses,  neuralgia,  and  functional  derangement  of 
the  female  organs  of  generation,  such  as  cessation  of  the  menses  and 
all  the  sympathetic  phenomena  of  the  change  of  life.  Hysteria, 
J nymphomania,  false  pregnancy,  hysteralgia,  anaphrodisia,  inertia  of 
the  womb,  mastodynia,  chlorosis,  dysmenia,  amenia,  amenorexia, 
arnenorrhcea,  dysmenorrhea,  menorrhagia,  raenostasis,  and  all  the 
^anomalies  of  menstruation. 


74 


VICIOUS  CONFORMATION  OF  GENITALS. 


VI.  Section. 


Lesions  apper- 
taining to 
Reproduction. 


r Comprising  the  accidents  and  all  the  sympathetic  phenomena  of  con- 
ception, pregnancy,  labour  and  lactation,  among  which  are  false  germs 
or  moles,  extra-uterine  pregnancy,  abortion,  strange  appetite,  ano- 
rexia, odontalgia,  ptyalism,  convulsions,  vomiting,  nervous  cramps  of 
the  stomach,  nervous  colic, constipation,  diarrhoea,  tenesmus,  dysuria, 
ischuria;  the  hernias  which  sometimes  complicate  pregnancy;  dys- 
pepsia, cough,  haemoptysis,  haematemesis,  epistaxis,  sanguine  ple- 
thora, palpitations,  syncope,  varices,  haemorrhoids,  oedema  of  the 
limbs,  cephalalgia,  vigils;  neuroses  of  sight,  hearing  and  smell;  neu- 
ralgia  of  the  loins,  kidneys,  groins,  pubis,  labia  and  thighs;  contusions 
and  lacerations  of  the  genital  parts ; inversion  of  the  womb  and  va- 
gina, puerperal  peritonitis,  milk  fever,  phlebitis  of  the  uterine  and 
ovaric  veins,  of  the  inferior  cava  and  the  crural  veins;  neuritis  of 
the  sciatic,  crural  and  sub-pubal  nerves;  painful  oedema,  phlegmo- 
nous abscess  of  the  mons  and  labia,  of  the  psoas  and  iliacus  mus- 
cles; absence,  diminution,  suppression  or  excess  of  the  lochia;  miliary 
eruption,  polygalactia,  agalactia,  retention  of  the  milk  in  the  breast, 
involuntary  flow  of  milk,  alterations  of  the  milk;  and  lastly,  mam- 
mary abscess,  mammary  fistula,  cracks,  excoriations,  flattening,  im- 
_perforation,  absence  and  multiplicity  of  the  nipple. 


FIRST  SECTION. 

CHAPTER  V. 

LESIONS  OF  FORM  AND  DEVELOPMENT. 

Vicious  conformation,  congenital  or  accidental,  of  the  female  genitais. 

Though  there  may  exist  cases  of  vicious  conformation  of  the 
female  genitals  that  are  beyond  the  resources  of  our  art,  such  as  ab- 
sence of  the  womb  and  vagina,  opening  of  the  vagina  into  the  blad- 
der or  rectum,  imperforation  of  the  Fallopian  tubes,  absence  of  the 
ovaries,  &c.,  &c.,  there  are  others  susceptible  of  remedy,  and  not  a 
few  such — as,  for  example,  the  complete  or  partial  cohesion  of  the 
labia  or  the  nymphas;  their  excessive  length;  too  great  a development 
of  the  clitoris;  occlusion  of  the  meatus  urinarius;  imperforation,  obli- 
teration and  obturation,  and  congenital  or  accidental  narrowness  or 
stricture  of  the  vagina;  and,  lastly,  occlusion  of  the  neck  of  the  womb. 

OCCLUSION  OF  THE  SEXUAL  ORGANS. 

The  occlusion  of  the  female  genitals,  which  has  been  noticed  from 
the  remotest  antiquity  by  the  Greek  physicians,*  was,  by  the  Latins, 
(Celsus,  lib.  7.  cap.  28,  JEtius,  lib.  16.  cap.  97.)  called  clausum , and 
by  the  Arabians,  (Avicenna,  21.  3.  tract.  4.  cap.  1,  and  Albucasis,  lib. 

* Girls  who  exhibit  this  faulty  conformation  received  from  the  Greeks  the  epithet 
of  arptirai — among  the  Romans  they  were  called  imperforatse  clausse  velatae ; Cicero  ( de 
Divinat.,  lib.  iii.)  speaks  of  a dream  in  which  was  seen  a woman  quae  obsigimtam 
habebat  naturaui;  and  Pliny  relates  that  Cornelia,  the  mother  of  the  Gracchi,  was 
born  with  an  imperforation  of  the  sexual  parts — concreto  genitali  naia  fuit.  {Hist. 
Natural .,  lib.  7.  cap.  16.) 


OCCLUSION  OF  THE  SEXUAL  ORGANS. 


75 


2.  cap.  72,)  alratica;  it  is  the  phymosis  of  Galen  and  Paulus  AEgi- 
netta,  (Paulus  iEgin.,  lib.  3.  cap.  73.  and  lib.  6.  cap.  71  and  72;)  the 
phymon  of  Ambrose  Pare,  (Ambroise  Pare,  liv.  4.  chap.  59.  p.  998,) 
and,  in  fine,  has,  by  most  of  the  modern  French  writers,  been  desig- 
nated by  the  words  atretism , atresia ,*  imperj oration. 

Although  the  words  union,  imperforation,  obliteration  and  obtura- 
tion are  not  synonymous,  and  present  totally  different  ideas  to  the 
mind,  one  of  these  expressions  is  often  used  to  designate  an  occlusion 
of  the  genitals,  whatsoever  may  happen  to  be  its  seat,  nature  or 
causes. 

In  order  to  establish  a more  exact  division,  and  give  to  the  words 
union,  imperforation,  obliteration  and  obturation  the  true  sense  and 
meaning  they  ought  to  express,  we  shall  distinguish  them  in  the  fol- 
lowing manner: 

We  shall  use  the  word  union  to  express  the  congenital  and  acci- 
dental coherence  of  the  labia  and  the  nymphse. 

The  words  imperforation,  atretism,  atresia  imperforatio,  atresia, 
will  indicate  the  occlusion  of  the  inferior  and  anterior  part  of  the 
vagina;  which  may  be  either  complete  or  incomplete,  accidental  or 
congenital;  and  which  may  depend  either  upon  the  presence  of  the 
hymen  or  any  other  imperforate  membranous  fold,  or  upon  cellular  or 
cellulo-fibrous  bands  situated  in  various  parts  and  at  different  heights 
in  the  canal  of  the  vagina. 

The  word  obliteration , from  the  Latin  word  obliterare , will  ex- 
press not  only  the  accidental  constriction  of  the  vagina,  but  also  the 
coherence  of  its  walls  throughout  its  entire  length,  or  in  its  middle, 
or  towards  either  extremity.  The  obliteration,  which  is  aliuays 
accidental , may,  therefore,  like  the  imperforation,  be  either  complete 
or  incomplete. 

Lastly,  the  word  obturation , from  the  Latin  obturare , will  indicate 
the  more  or  less  complete  occlusion  of  the  womb  or  of  the  vagina; 
which  may,  when  it  is  accidental,  be  occasioned  by  excrescences,  by 
polypus,  by  hydatids,  by  tumours  of  different  sorts;  or,  when  conge- 
nital by  means  of  some  intermediate  substance  of  a fibrous,  cellular 
or  cellulo-fibrous  nature. 

The  occlusion  of  the  genital  organs  of  the  female,  whatever  be  the 
nature  and  cause  of  it,  is  the  more  especially  deserving  of  the  atten- 
tion of  the  practitioner,  inasmuch  as  it  obstructs  the  exercise  of  several 
important  functions,  and  may  often  compromise  not  only  the  health 
but  the  life  and  the  reputation  of  the  patient. 

As  this  subject  has  been  but  little  studied,  and  mention  is  scarcely 
made  of  it  in  works  treating  of  female  diseases,  we  shall  dwell  upon 
it  at  greater  length  than  has  been  done  by  our  predecessors  upon 
the  history,  etiology,  differential  signs,  diagnosis  and  treatment  of  the 
various  primary  and  accidental  occlusions  of  the  sexual  organs. 
We  shall  also,  in  the  same  chapter,  treat  of  all  the  faulty  conforma- 
tions, whether  congenital  or  whether  developed  after  birth  and  at  all 
the  periods  of  life. 


From  the  Greek  priv.  a,  without  opening . 


76 


UNION  OF  THE  LABIA. 


OF  THE  UNION  OF  THE  LABIA  AND  OF  OTHER  FAULTY  CONFORMA- 
TIONS OF  THE  VULVA  AND  ITS  PARTS. 

We  sometimes  find  that  female  children  are  born  with  a more  or 
less  complete  cohesion  of  the  labia,  so  that  these  bodies  are  united  in 
the  whole  or  in  a part  only  of  their  length.  When  the  cohesion  is 
complete  nothing  can  be  seen  but  a sort  of  raphe  or  seam,  without 
any  trace  of  clitoris  or  vagina,  or  urethral  orifice.  The  labia,  which 
are  prominent,  constitute  a soft,  elastic,  fluctuating  tumour,  and  there 
is  found  above  the  pubis  a rounded  elevation  occasioned  by  the 
accumulation  of  the  urine  in  the  bladder,  and  which  is  very  painful 
upon  the  least  pressure. 

This  complete  absence  of  the  genital' fissure,  the  result  of  aeon- 
genital  deformity,  is  announced  soon  after  birth  by  the  continual  cries 
of  the  child,  and  by  all  the  signs  proper  to  a suppression  of  urine.  In 
such  a case  death  is  the  inevitable  consequence  if  measures  be  not 
taken  to  re-establish  the  natural  openings. 

In  some  cases  where  the  vulva  is  not  imperforate  through  its 
whole  length,  the  urethra  is  sufficiently  open  to  give  issue  to  the 
urine ; in  others,  the  fluid  escapes  drop  by  drop,  and  with  greater 
difficulty  in  proportion  as  the  cohesion  of  the  labia  is  more  or  less 
extensive,  leaving  more  or  less  liberty  to  the  orifice  of  the  meatus 
urinarius.  In  the  former  case,  that  is,  where  the  urine  escapes 
freely,  the  infirmity  under  question  does  not  interfere  with  the 
health  of  the  young  girl,  and  it  is  not  until  the  period  of  puberty  that 
it  gives  rise  to  the  disorders  caused  by  retention  of  the  menstrual 
fluid,  concerning  which  we  shall  have  to  treat  in  a future  chapter. 

Where  the  partial  union  of  the  labia  affects  the  lower  part  of  the 
vulva,  there  is  always  a discharge  of  urine  into  the  vagina,  which, 
by  its  accumulation  there,  may  produce  mischievous  effects,  such  as 
ulceration  of  the  walls,  fistulas  of  the  rectum  and  perineum,  and  a 
multitude  of  other  accidents. 

Schultz,  ( Miscel . cur  Germ.,  obs.  3.  Decemb.  1.  anno.  10,)  relates 
that  a little  girl,  four  years  old,  had  been  unable,  since  her  birth,  to 
discharge  the  urine  except  drop  by  drop,  and  that  with  extreme  pain 
and  difficulty.  The  parents,  supposing  she  had  a stone  in  the  blad- 
der, consulted  a surgeon,  who  discovered  an  almost  complete  union 
of  the  labia.  He  destroyed  the  adhesion  and  established  the  free 
course  of  the  urine  by  means  of  an  incision  with  a convex-edged 
bistoury. 

The  lesion,  whether  complete  or  partial,  of  the  labia  is  not  always 
congenital ; it  may  depend  upon  certain  accidental  disorders ; thus  it  is 
sometimes  occasioned  by  acute  inflammation  of  the  vulva  either  attack- 
ing spontaneously,  or  brought  on  by  the  effects  of  laborious  labour,* 

* Marcellus  Donatus,  De  Med.  Histor.  Mirab.,  lib.  6.  cap.  2;  Riolan,  sen.,  art.  bene 
medendi,  sec.  4.  tract.  2.  cap.  1;  Felix  Plater,  Obs.,  lib.  1.  p.  258;  Casp.  Bauhin, 
Theat.  Anatom.,  lib.  1.  cap.  39,  and  De  Hermaphrodilis , lib.  1.  cap.  38;  Fabr.  Hildan, 
Obs.  centur,  lib.  6.  obs.  67;  Riolan,  jun.,  Enchirid.  Anat.,  lib.  ii.  cap.  37,  and  Anthro- 
pograph.  lib.  2.  cap.  35.  p.  197;  Th.  Bartholin,  Hist.  Anatom.,  centur,  ii.  histor.  31; 
Rudolph  Jacob  Camerarins,  Misc.  Nov.  Curios.  German.,  centur,  9,  io.  obs.  73;  J. 
Conrad  Beckerus,  De  Inculpata,  § 18,  and  seq.;  Roonhuysen,  Obs.  Chirurg.,  obs.  2.  p. 
125  ; Heister,  Institut.  Chirurg n torn.  ii.  p.  9.  52. 


UNION  OP  THE  LABIA. 


77 


of  a burn,*  of  a venereal  affection, t a wound  or  a laceration.^  It 
may  likewise  depend  upon  the  long-continued  friction  of  any  hard 
substance;§  upon  frequently  repeated  coitus;||  upon  excoriations  pro- 
duced by  the  acrimony  of  the  urine  in  children  yet  wearing  the 

* G.  de  Sorbait,  Eph.  Curios . Nat.  de  Cur.  1.  ann.  3.  obs.  273,  and  Chambon,  who, 
in  his  Traite  des  Maladies  des  Femmes, chap.  37.  p.  299,  cites  from  this  author  the  case 
of  a young  girl  eight  years  of  age,  who,  as  she  was  warming  herself  by  an  earthen 
pot  filled  with  lighted  coals  and  covered  over  with  ashes,  by  a sudden  motion  overset 
the  vessel,  so  as  to  produce  a burn  of  the  vulva  and  lower  part  of  the  vagina.  As 
little  attention  was  paid  to  the  consequences  of  the  accident,  the  inner  surfaces  of 
the  labia  cohered  as  they  got  well,  and  there  was  left  only  a small  hole  in  the  middle 
of  the  vulva,  through  which  the  menses  escaped  regularly.  At  a later  period,  the 
girl  having  abandoned  herself  to  the  caresses  of  her  lover,  she  became  pregnant, 
notwithstanding  the  narrow  dimensions  of  the  opening.  The  adhesions  were  sepa- 
rated from  the  orifice  just  mentioned  to  a point  below  the  orifice  of  the  urethra,  but 
the  dilatation  proving  to  be  insufficient,  the  incision  was  prolonged,  and  the  labour 
terminated  happily. 

f Anton- Beneveni,  de  abditis  nonnulis  morbis , et  san  causis,  cap.  31;  also,  La 
Lancette  Fran  guise,  Gazette  des  Hopiteaux , No.  31.1.  vii.  Mar.  1833. 

* The  illustrious  Dupuytren  has  given,  in  his  Lectures,  the  case  of  a girl  who 
was  seduced,  and  who,  in  giving  birth  to  a child,  was  delivered  precipitately  and 
with  violence;  the  consequence  of  which  was  a deep  laceration  of  the  perineum, 
with  severe  inflammation  of  the  vulva.  The  learned  professor  brought  the  parts 
together  by  means  of  three  sutures.  After  the  lapse  of  two  years,  without  his  having 
heard  from  her,  she  called  upon  him  to  request  that  he  would  say  nothing  <on  the  sub- 
ject of  her  misadventure  to  her  husband,  who  was  to  call  upon  him  the  next  day  for  his 
advice.  In  fact,  he  called  in  order  to  consult  with  M.  Dupuytren  as  to  the  measures 
to  be  taken  for  overcoming  the  resistance  dependent  on  the  virginity  of  his  wife,  in 
consequence  of  which  the  marriage  could  not  be  accomplished.  A new  operation 
removed  the  difficulty,  without  his  having  the  least  suspicion  of  her  past  history. 
The  medical  annals  contain  a great  number  of  similar  cases — I had  an  opportunity 
of  seeing  one  not  less  curious  at  La  Charite,  in  the  wards  of  Baron  Boyer. 

§ Arnaud  (Obs.  1.  p.  44,)  relates  the  case  of  a young  girl,  whose  genitals  were 
excoriated  and  violently  irritated  by  a long  ride  upon  an  ass,  whose  rude  trot  and  the 
hardness  of  the  pack-saddle,  were  the  occasion  of  the  misfortune.  Having  taken  no 
care  of  herself,  the  labia  cohered  without  her  having  dared  to  speak  of  it,  and  the 
vulva  presented  but  two  small  orifices;  one  through  which  the  menses  escaped,  and 
the  other  opposite  to  the  meatus  urinarius.  Notwithstanding  the  almost  complete 
occlusion  of  the  vulva,  she  married  and  became  pregnant.  When  her  labour  came 
on,  the  cohering  parts  were  divided  with  probe-pointed  scissors,  and  the  delivery  was 
happily  accomplished. 

H In  1814,  there  came  to  the  Hotel-Dieu  at  Paris,  a woman,  twenty-four  years  of 
age,  well  formed,  and  of  a sanguine  temperament.  She  came  for  advice  as  to  a 
tumour  of  the  hypogaster,  which  she  supposed  to  arise  from  suppression  of  the 
menses.  Upon  a careful  examination  of  the  sexual  organs,  it  was  found  that  the 
vulva  was  completely  obliterated,  and  the  womb  greatly  distended,  forming  a globe 
about  the  size  of  the  uterus  at  the  sixth  month  of  gestation.  Being  carefully  interro- 
gated as  to  the  possible  causes  of  her  disorder,  she  confessed  that  having  been  sur- 
prised by  some  Cossacks  in  the  woods  at  Fontainebleau,  she  had  been  compelled  to 
submit  to  several  of  them,  and  she  regarded  her  malady  as  really  caused  by  this  vio- 
lence. Notwithstanding  the  use  of  venesection,  leeches,  baths,  fomentations,  narco 
tics,  &c.,  her  situation  became  so  dangerous  that  Dupuytren  decided  to  use  the  bis 
toury,  in  order  to  overcome  the  adhesions  of  the  organs  ; and  the  consequence  was  a 
copious  discharge  of  black  putrid  blood,  exhaling  an  infectious  odour.  For  fear  of 
impeding  the  discharge  of  matters  already  so  long  retained,  no  dressings  were  em 
ployed.  On  the  following  day  a complete  relief  had  succeeded  the  most  violent  ago- 
nies. The  abdominal  tumour  was  very  much  lessened.  The  discharge  was  still 
considerable  and  bloody ; a suppurative  fever  came  on  and  lasted  a few  days,  and  the 
discharge,  which  had  become  puriform,  next  became  mucous.  In  order  to  obviate 
th§  tendency  to  cohesion,  she  was  advised  to  introduce  a dilater  into  the  vulva  from 
time  to  time,  and  the  cure  was  soon  complete.  This  curious  case  is  related  in  detail 
in  the  Lancette  Frangaise , N.  31.  6th  annee,  7. 7. 


78 


UNION  OF  THE  LABIA. 


napkin;  (Isbrand  de  Diemerbroek,  Anat.  du  Coi'ps  Humam,  bb.  1. 
cap.  26  ;)  and  lastly,  by  large  variolous  pustules  under  suppuration, 
(Becker,  jr.,  in  Pcedioctonia  Inculpata,  fyc.,  p.  35;  Boyer,  Malad. 
C/iintrg.,  xx.  p.  379  ;)  and  a variety  of  other  circumstances  capable 
of  exciting  violent  inflammation  of  the  genitals. 

There  is  yet  another  cause  of  atresia  (complete  or  incomplete)  of 
the  vulva,  but  which  exists  only  among  the  oriental  nations.  Many 
authors,  and  among  them  Sinibaldus,  (Geneanthropia,  lib.  4.  cap.  12, 
Rodericus  a Castro,  lib.  4.  cap.  10,)  state  that  in  Ethiopia  the  virginity 
of  the  females  is  made  sure  of  by  uniting  the  sides  of  the  labia  as 
soon  as  they  are  born.  United  by  sutures  made  with  silken  threads, 
space  is  left  sufficient  only  for  the  natural  discharges : when  married, 
the  husband  makes  the  section  required  for  the  restoration  of  the 
natural  form. 

Atresia  of  the  vulva  is  not  always  the  inevitable  consequence  of 
the  causes  we  have  above  signalized ; and  where  it  does  take  place 
under  such  circumstances,  it  is  because  the  inflammation  arising  has 
been  neglected  or  badly  managed. 

Whatsoever  may  have  been  the  occasion  of  this  vulvar  symphysis, 
it  is  to  be  cured  by  re-establishing  or  completing  the  external  ori- 
fice of  the  vagina,  by  means  of  a bistoury  guided  upon  a grooved 
director,  and  conducted  longitudinally  upon  the  middle  of  the  abnor- 
mal raphe  formed  by  the  agglutination  of  the  labia.  To  prevent 
the  reunion  of  the  surfaces  until  after  the  cicatrization  is  completed, 
a bit  of  lint,  or  what  is  better,  a small  compress  spread  with  cerate, 
should  be  interposed.  When  the  occlusion  is  complete,  the  operation 
ought  to  be  done  as  soon  as  possible  after  the  birth  of  the  infant,  for 
the  least  delay  might  produce  fatal  consequences.  But  if  the  cohe- 
sion has  left  free  course  for  the  urine,  and  has  not  been  discovered 
until  towards  puberty,  and  is  disclosed  by  the  symptoms  of  accumu- 
lation of  the  menses  in  the  vagina  and  in  the  womb,  we  should  ope- 
rate as  has  already  been  mentioned ; but  it  would  be  most  prudent 
to  make  only  a small  opening,  so  as  to  allow  the  blood  to  escape 
slowly,  in  order  that  the  distended  parts,  recovering  by  slow  degrees, 
may  be  less  liable  to  the  violent  and  often  fatal  inflammation  that 
follows  the  too  sudden  evacuation  of  fluids  contained  within  the 
visceral  cavities.  To  assist  in  cleansing  the  organs,  recourse  should 
be  had  to  emollient  lotions  and  baths,  to  be  followed  according  to 
circumstances,  and  the  state  of  the  case  as  to  its  symptoms,  by  deter- 
gent, and  in  some  instances,  by  antiseptic  injections. 

When  the  discharge  of  blood  has  ceased  and  the  parts  have  reco- 
vered their  normal  state,  if  the  method  above  recommended  has  been 
taken,  the  operation  ought  to  be  completed  by  completely  separating 
the  labia,  as  before  directed. 

Whether  the  operation  be  performed  soon  after  the  birth  of  the 
child,  or  whether  the  case  admits  of  our  waiting  for  a later  period, 
not  only  should  we  make  use  of  a plaster  spread  with  cerate  to  pre- 
vent the  reunion,  but  it  is  advisable  to  touch  the  whole  surface  of 
one  labium  with  nitrate  of  silver.  These  two  labia,  being  no  longer 
in  the  same  condition  in  consequence  of  the  cauterization  of  one  of 


OF  COHESION  OF  THE  NYMPHiE. 


79 


them  only,  it  follows  that  they  will  be  less  likely  to  cohere,  and  thus 
the  good’effects  of  the  operation  will  be  more  easily  obtained. 

Union  of  the  labia,  even  when  incomplete,  is  an  obstacle  to  the 
union  of  the  sexes,  and  when,  in  such  cases,  conception  has  taken 
place,  as  has  often  happened,  as  shown  by  the  annals  of  medicine, 
the  deformity  continues  until  the  attack  of  labour  has  rendered  an 
operation  inevitable. 

OF  COHESION  OF  THE  NYMPHO. 

Congenital  cohesion  of  the  nymphse  always  accompanies  that  of 
the  labia,  but  may  exist  without  the  latter,  and  may  be  the  result  of 
a primary  or  accidental  vice. 

We  had  occasion,  in  the  course  of  the  present  year,  (February, 
1837,)  to  operate  upon 'a  child  two  years  old,  supposed  to  be  labour- 
ing under  stone,  from  the  great  difficulty  of  passing  off  the  urine. 
Having,  by  a careful  examination,  ascertained  that  the  difficulty 
arose  from  a congenital  cohesion  of  the  nymphse,  which  seemed  to 
be  wholly  wanting,  or  rather  to  have  as  their  substitute  a fleshy  mem- 
brane of  a triangular  shape  and  of  a bright-red  colour,  and  placed 
at  right  angles  upon  the  spot  usually  occupied  by  the  meatus,  and 
presenting  at  its  base  a small  orifice  directed  from  below  upwards — 
a small  elastic  bougie,  introduced  within  this  urethral  orifice,  was 
promptly  arrested  by  a narrow  cul-de-sac  about  four  or  five  lines  in 
depth.  This  arrangement  explains  why  the  urine  could  not  escape 
in  a direct  line,  but  was  compelled  to  dribble  away  obliquely  back- 
wards and  from  above  downwards,  constantly  bathing  the  labia  and 
th§  fossa  navicularis,  which  had  become  much  inflamed  by  the  almost 
constant  contact  of  the  fluid  of  the  bladder. 

Having  introduced  behind  the  nymphae  the  extremity  of  a guarded 
bistoury,  which  I use  in  operating  for  fistula  in  ano  and  for  relieving 
the  stricture  in  hernia,  1 destroyed  the  adhesion,  by  depressing  the 
handle  of  the  instrument,  with  a single  incision.  For  the  purpose  of 
obviating  the  consecutive  adhesion,  I touched  one  of  the  surfaces 
with  nitrate  of  silver ; nevertheless,  this  precaution  did  not  seem  to 
be  an  indispensable  one,  inasmuch  as  the  frequent  contact  of  the 
urine  would,  probably,  have  sufficed  to  prevent  any  new  agglutina- 
tion of  the  parts. 

Professor  Duges,  in  the  Trait'e  des  Mai.  de  V Uterus , which  he  pub- 
lished in  conjunction  with  Madame  Boivin,  says  that  a little  girl  was 
brought  to  him  to  inquire  as  to  the  cause  of  a habitual  dysury  that  she 
laboured  under.  The  urine  escaped  by  a small  orifice  near  the  clito- 
ris. A probe  introduced  into  it  did  not  pass  into  the  bladder,  but, 
when  directed  horizontally  backwards,  entered  the  vagina  near  its 
orifice.  There  was  no  appearance  of  nymphas  ; and  we  ascertained, 
says  M.  Duges,  that  they  were  coherent,  and  composed  a canal 
placed  at  right  angles  to  the  orifice  of  the  urethra  so  as  to  receive 
the  urine  and  allow  it  to  escape,  partly  above  near  the  clitoris  and 
partly  below  near  the  vagina.  This  case  differs  from  the  one  I have 
just  related  only  in  this,  that  the  urine  escaped  both  above  and  below, 


80 


EXCESSIVE  DEVELOPMENT  OF  THE  NYMPHiE, 


while,  in  my  case,  it  dribbled  away  only  below,  that  is  to  say,  ob- 
liquely from  above  downwards.  It  should  be  added  that  Dr.  Buet 
has  published  a case  very  similar  to  those  just  mentioned.  ( Journ . 
Comp.,  t.  39.  p.  223.) 

The  chirurgical  measures  adapted  to  these  deformities  consist 
simply  in  separating  the  nymphae  at  the  line  of  coherence,  by  an 
incision,  guiding  the  bistoury  upon  a grooved  sound,  as  M.  Duges 
did,  and  making  use  of  the  precautions  we  recommend  in  speaking 
of  the  symphysis  of  the  labia  pudendi.  The  guarded  bistoury  which 
we  used,  and  which  is  hardly  half  a line  in  diameter,  fulfils  this  indi- 
cation most  perfectly,  and  renders  the  operation  not  only  prompt  but 
exempt  from  all  danger,  notwithstanding  the  movements  of  the  child. 


OF  EXCESSIVE  DEVELOPMENT  OF  THE  NYMPHIE. 

As  we  have  already  stated  at  p.  44,  the  nymphae  are,  in  common 
with  the  clitoris,  susceptible  of  becoming  so  much  elongated  that  they 
not  only  interfere  with  the  act  of  coition,  but  become  inflamed  and 
excoriated  in  consequence  of  their  friction  in  walking,  and,  in  some 
instances,  ulcerate  so  badly  as  to  require  excision  for  the  cure. 

This  operation,  which,  in  Egypt,*  is  a very  common  one,  is  also 
in  use  in  Ethiopia,!  in  Syria,  among  the  Cops,!  t^e  Arabs  and  the 
inhabitants  of  Malabar, § and  it  possesses  even  the  force  of  law|| 
among  most  of  the  oriental  nations,  whose  women,  like  those  of 
the  negro  races,  are  generally  subject  to  elongation  of  the  nymphae. 

Many  travellers,  however,  report  that  all  the  women  are  not  sub- 
jected to  the  operation  in  question,  and  that  it  is  practised,  as  a gene- 
ral custom,  only  in  certain  countries  in  Arabia  and  Persia,  near  the 
Persian  Gulf  and  the  Gulf  of  Ormus,  (Chardin,  Voyages  en  Perse,  tom. 
iii.  p.  207;  Wlesling,  p.  144;)  the  Abyssiniatis,  although  a Christian 
people,  and  the  women  of  the  kingdom  of  Juida,  who  are  neither  Jews 
nor  Mahometan,  still  preserve  this  ancient  rite,  which  is  not  due  to  the 
jealousy  of  the  oriental  tribes,  but  is  made  use  of  by  them.  With  the 
view  of  preventing  a pretended  deformity,  they  operated  on  all  the 
young  girls  as  soon  as  they  attained  a marriageable  age,  under  the 
persuasion  that,  by  shortening  the  nymphse  and  thereby  diminishing 
the  frictions,  they  lessened  the  provocations  to  lubricity.  The  Turks 
appear  to  have  another  end  in  view  in  the  practice  of  nymphotomy. 
According  to  Sonnini,  their  object  is  to  remove  all  the  inequalities  of 
the  parts  for  the  purpose  of  facilitating  the  congress.  According  to  Leo 
African  us,  (lib.  viii.,)  there  are,  in  certain  countries  in  Africa,  where 
enlargement  of  the  nymphse  is  very  common,  certain  men  whose  sole 
business  it  is  to  excise  whatever  is  too  exuberant  in  the  structure  of 
the  external  genitals.  The  same  author  adds  that  these  operators 
cry  aloud  in  the  streets,  “ tV/io  is  she  that  ivishes  to  be  cut?”  In 
his  Travels  in  Upper  and  Lower  Egypt,  published  in  1799,  Sonnini 

* Sonnini,  Travels  in  Upper  and  Lower  Egypt,  tom.  i. 

+ Leo  African.,  lib.  iii.;  Demarchai’s  Voyages;  tom.  iii.  chap.  vii.  p.  153. 

$ Bellon,  Observ.,  p.  4*26.  § Voyage  de  Thevenot,  cap.  32. 

y Paul.  iEginetta,  lib.  iv.  cap  70;  ^Etius  Tetrabib  IV.,  Strabo,  lib.  vii. 


EXCESSIVE  DEVELOPMENT  OF  THE  NYMPHiE. 


81 


also  tells  us  that  the  excision  of  the  nymphae  and  clitoris  is  still  prac- 
tised in  those  countries,  upon  girls  of  seven  or  eight  years  of  age;  and 
that  the  operation,  in  Upper  Egypt,  is  always  performed  at  the  time 
of  the  increase  of  the  Nile,  by  women  who  go  about  in  the  public 
streets  of  Cairo  crying  their  trade  in  the  words,  “ Here’s  ct  good  circa  m- 
ciser !”  A razor  and  a pinch  of  ashes  comprise  the  whole  apparatus 
for  this  excision. 

Although  the  operation  of  nymphotomy  may  have  been  originally 
established  for  the  purpose  of  obviating  the  unmeasured  augmenta- 
tion of  the  nymphae,  it  may  possibly  have  been  instituted  also  for  the 
purpose  of  maiptaining  the  cleanliness  of  the  sexual  organs;  for  in 
the  negroes  and  Coptic  women,  whose  nymphae  are  very  long,  there 
is  collected,  betwixt  the  clitoris  and  nymphae,  a quantity  of  sebaceous 
matter  of  a whitish  colour  that  becomes  acrid  and  stimulating,  and 
that  moreover  exhales  in  those  females  a very  fetid  miasma. 

The  Portuguese  Jesuits,  who,  in  the  sixteenth  century,  converted  the 
people  of  Abyssinia  to  Christianity,  were  desirous  of  abolishing  this 
custom  as  a remains  of  Mahomedanism,  but  the  girls  that  remained 
uncircumcised  obtained  no  husbands,  and  were  looked  upon  as  so 
unclean  that  the  very  vessels  in  which  they  ate  were  broken.  The 
Pope,  upon  the  recommendation  of  some  surgeons  who  were  sent 
there,  authorized  the  practice  of  circumcision,  which  was  looked 
upon  as  a hygieinic  and  cleanly  precaution  for  the  sex. 

Notwithstanding  that  exuberant  growth  of  the  nymphae  is  a pretty 
rare  anomaly  in  European  countries,  especially  in  our  climate,  we 
nevertheless  meet  with  instances  of  their  projecting  beyond  the  ori- 
fice of  the  genitalia  several  lines,  or  even  several  inches.  Where 
the  increased  size  is  accidental,  it  may  depend  upon  inflammatory 
swelling,  upon  relaxation  of  the  tissues  or  hypertrophic  action.  In 
such  a case,  the  salient  portion  becoming  irritated  and  painful  from 
the  friction  of  the  clothing,  or  the  motions  of  the  thighs,  the  exposed 
surface  ulcerates,  and  the  woman  is  obliged  to  remain  at  rest.  In  most 
cases  the  use  of  baths  and  of  emollient  and  narcotic  fomentations,  rest, 
a horizontal  posture,  &c.,  suffice  for  the  dissipation  of  this  accidental 
enlargement  of  the  nymphae;  but  cases  are  met  with  in  which  these 
measures  will  not  answer  the  purpose,  and  we  are  compelled  to  have 
recourse  to  the  excision.  Mauriceau,  in  his  Observ.  cxxxiv.,  relates 
the  case  of  a lady  who  vehemently  implored  him  to  perform  the  ope- 
ration for  her,  as  well  because,  being  obliged  to  be  often  on  horseback, 
the  elongation  of  the  nymphae  gave  her  pain  from  the  friction,  as 
because  the  indecency  of  the  malady  was  as  displeasing  to  herself 
as  it  was  to  her  husband.  P.  30,  Traill  des  Mad  ad.  des  Femmes. 

Excessive  elongation  of  the  nymphae  is  not  the  only  circumstance 
that  renders  their  excision  necessary ; for  recourse  should  be  had  to 
it  in  cases  where  they  tyave  become  fungous,  scirrhous,  carcinomatous 
or  gangrenous,  &c.,  disorders  that  may  arise  in  consequence  of  con- 
tusion or  injury  experienced  in  laborious  labour,  from  venereal  taint, 
or  even  from  inappreciable  causes. 

The  excision  of  the  nymphae,  which  has  been  described  by  Galen, 

( de  usu  Partium ,)  JEtius,  ( Tetrabib .,  lib.  v.  serm.  4,)  Paul.  iEgi- 
6 


82 


EXCESSIVE  DEVELOPMENT  OF  THE  NYMPHJE. 


netta,  (lib.  vi.,)  Moschion,  Suidas,  ( Lexic . 81,)  Albucasis,  (lib.  ii. 
cap.  vii.,)  Avicenna,  (lib.  iii.  sen.  21.  tract,  v.  cap.  24,)  Mathias, 
Zimmermann,  ( De  JEthiopum.  Circumcis.  cap.  9,)  Dionis,  Levret  and 
many  other  modem  authors,  is  performed  in  the  following  manner: 
the  woman  having  been  placed  in  the  same  position  as  that  which 
has  been  directed  in  case  of  the  use  of  the  speculum,  the  surgeon, 
after  separating  the  labia,  seizes,  with  a broad  forceps  or  with  the 
thumb  and  first  three  fingers  of  his  left  hand,  the  left  nympha,  and 
performs  the  section  with  a scissors  curved  upon  the  flat  surface, 
and  held  in  his  right  hand.  Having  completed  the  first  section,  he 
takes  the  other  nympha  in  like  manner  with  the  right  hand,  and, 
holding  the  scissors  in  the  left,  performs  the  excision  of  the  organ. 
If  the  sole  motive  for  the  operation  consists  in  the  mere  excessive 
magnitude  of  the  organ,  care  ought  to  be  taken  not  to  remove  more 
than  the  excess ; but  where  the  operation  is  performed  on  account 
of  gangrene  or  carcinoma,  the  extent  of  the  section  should  correspond 
to  the  necessity  for  excision,  and  the  instrument  should  even  be  car- 
ried into  the  sound  tissues.  The  operation  being  completed,  a gum- 
elastic  catheter  should  be  introduced  into  the  urethra  and  left  in  the 
canal.  Each  wound  ought  to  be  dressed  with  a dossil  of  dry  lint, 
supported  by  small,  narrow  compresses,  and  by  a T bandage,  slit 
opposite  to  the  end  of  the  catheter. 

In  case,  as  in  Mauriceau’s  patient,  copious  haemorrhage  should  fol- 
low the  section,  which  is  very  improbable,  since  the  vessels  of  the 
nymphae  are  quite  small,  the  flow  would  be  readily  controlled  by 
aluminous  lotions,  or,  if  need  should  be,  by  the  application  upon  the 
cut  surfaces,  of  small  pieces  of  agaric  cut  into  a conical  shape,  or 
by  bunches  of  lint  sprinkled  with  rosin,  and  sustained  in  situ  by  a 
bandage  and  compress.  Recourse  could  also,  if  required,  be  had  to 
the  use  of  nitrate  of  silver  or  the  actual  cautery ; but  if  the  vessel 
should  be  pretty  large,  it  could  be  secured  by  the  ligature. 

OF  UNNATURAL  DEVELOPMENT  OF  THE  CLITORIS,  AND  OF  ITS 

EXCISION. 

As  has  already  been  shown  at  page  45,  the  clitoris  is  capable  of 
acquiring  dimensions  even  beyond  those  of  the  male  penis.  It  is  easy 
to  imagine  why  an  exuberant  growth  of  this  organ  must  interfere 
with  the  functions*  of  the  sexual  parts,  and  become  the  source  of  a 
depravation  equally  disgraceful  and  disgusting.!  For  the  purpose  of 
obviating  the  inconvenience  and  the  bad  habits!  arising  from  this 

* Paul  Zacchias,  physician  to  Pope  Innocent  X.,  who,  though  a diffuse  writer,  is 
distinguished  for  his  immense  erudition  and  sound  judgment,  speaks  of  a Roman 
lady  who  could  not  cohabit  with  her  husband,  because  of  her  clitoris,  which  was  then 
in  a state  of  erection,  and  thus  was  an  obstacle  to  the  sexual  union.  Quest.  Med. 
Leg.  Avenione , pars  prirna  in  fo.  1660. 

| Martial,  lib.  i.,  addressed  the  following  to  Bassa, 

Essa  Videbaris,  faleor,  Lucretia  Nobis  ; 

At  tu,  pro  facinus!  Bassa,  fututor  eras, 

Inter  se  geminas  audes  committere  cunnos, 

Mentitur  que  virum  prodigiosa  Venus. 

f Avicenna,  under  the  word  Albathara,  i.  e.,  clitoris,  recommends  its  excision  in 
women  who  might  abuse  the  preternatural  organ. 


DISEASES  OF  THE  CLITORIS. 


83 


anomaly  of  structure,  and  the  excessive  sensibility  of  the  clitoris, 
the  excision  of  the  organ  has  been  recommended,  in  the  same  man- 
ner as  it  is  practised  in  certain  morbid  affections  of  it  of  a cancerous 
nature. 

In  performing  the  operation,  which  is  extremely  simple,  let  the 
woman  be  placed  as  for  the  use  of  the  speculum.  Having  seized 
the  part  with  a tenaculum  or  dissecting  forceps,  it  may  be  removed 
at  a stroke,  either  by  means  of  curved  scissors  or  by  means  of  a bis- 
toury, cutting  obliquely  and  as  near  as  possible  to  the  pubis.  The 
bleeding  almost  always  stops  spontaneously  ; if  it  should  be  too  con- 
siderable, it  might  be  arrested  by  the  ligature,  by  nitrate  of  silver,  or 
by  the  cautery. 

[Cases  of  the  kind  just  now  treated  of  by  M.  Colombat  must  be  very 
rare  in  this  country,  and  are,  probably,  so  in  all  Christendom.  Having 
been  many  years  engaged  quite  extensively  in  obstetric  practice,  and  in  the 
management  of  the  diseases  of  women  and  children,  in  this  great  city,  I 
have  never  seen  nor  heard  of  a case  of  excessive  magnitude  of  this  organ; 
save  one — and,  as  that  case  was  of  a most  singular  character,  I shall  report 
it  as  under  the  care  of  Dr.  George  Norris,  one  of  the  surgeons  of  the  Penn- 
sylvania Hospital,  who  operated  for  the  case  in  my  presence. 

Mrs.  W.,  aged  36,  was  affected,  fourteen  years  ago,  with  a slight  swelling 
at  the  top  of  the  genital  fissure,  which  gradually  increased  in  size  until  it 
attained  a very  considerable  magnitude  ; it  began  after  a blow  on  the  part. 
She  was  married  in  1836,  eight  years  ago.  During  the  eight  years  in  ques- 
tion, she  gave  birth  to  two  healthy  children,  and,  so  late  as  1839,  became 
the  mother  of  a daughter. 

During  her  lyings-in,  she  asked  the  opinion  of  her  accoucheur  on  the 
nature  of  her  malady,  and  was  by  him  referred  to  a surgeon.  In  the  fall  of 
1843,  it  was  shown  to  me,  and  in  the  month  of  May,  1844,  I saw  it,  in 
company  with  Dr.  George  Norris,  of  the  Pennsylvania  Hospital. 

The  drawing  of  the  tumour,  which  is  annexed,  gives  a very  correct  idea 
of  its  form  and  situation,  and  was  taken  by  myself  ad  vivum,  and  engraved 
by  Mr.  Gilbert. 

It  was  indolent.  It  sprung  from  the  upper  commissure  of  the  vulva. 
Its  superior  part,  or  dorsum,  was  composed  of  a true  skin  or  derm,  and 
was  sparsely  supplied  with  pudendal  hairs.  This  portion  was  of  a dusky 
colour,  like  that  of  the  exterior  pudendum  generally.  The  tumour  gravi- 
tated betwixt  the  thighs  as  the  patient  laid  on  her  back,  and  was  always 
pendulous  in  walking. 

Upon  lifting  up  the  tumour,  whose  neck  was  small  and  perfectly  flexible, 
the  inferior  surface  was  seen  of  a rose  tint,  of  a moderately  pale  colour,  like 
that  of  the  lip,  and  was  not  dermal  but  mucous  in  its  structure.  The  root  of 
the  tumour  separated  the  superior  part  of  the  labia,  portions  of  which,  as 
well  as  of  the  lower  part  of  the  mons  veneris,  had  been  drawn  upwards 
from  the  sides  and  downwards  from  above,  to  furnish  the  material  for  the 
development  of  the  new  structure.  I looked  for  the  nympho,  and  found 


84 


THE  CLITORIS. 


Fig.  10. 


that  they  also  had  been  drawn  in,  to  furnish  part  of  the  material,  for  they 
were  extended  up  on  each  side,  and  rendered  very  thin,  as  represented  in 
the  cut , whose  curved  edge  is  there  seen.  The  observer  will  please  take 
notice  of  a small  second  curved  line,  which  is  at  last  lost  in  ascending  upon 
the  sides  of  the  tumour.  That  line  is  the  anterior  edge  of  the  praeputium  cli- 
toridis,  which,  in  the  natural  state,  is  a sort  of  hood,  or  semicircular  fold  of 
the  top  of  the  nymphae,  which  covers  and  partially  conceals  the  clitoris, 
and  resembles  the  male  prepuce.  But,  in  this  specimen,  it  is  so  thin  that  it 
is  gradually  blended  with  the  mass  of  the  swelling  : the  same  appearances  are 
observable  on  the  other  side  of  the  tumour. 

The  sensibility  of  the  superior  part  of  the  mass  is  the  ordinary  dermal  or 
tactile  sensibility  ; whereas,  the  inferior  or  ventral  surface  and  part  of  the 
sides  were  endowed  in  a high  degree  with  the  erotic  clitoridian  sensibility. 
This  was  a point  which  I was  desirous  to  ascertain,  and  the  information  on 
it,  given  to  me  by  the  patient,  was  clear  and  candid. 

The  tumour,  whose  form  is  accurately  represented  in  the  drawing,  had  a 
dull  fluctuation,  and  the  handling  of  it,  and  even  smart  compression  of  it 
betwixt  the  fingers,  gave  no  pain.  Dr.  Norris  proposed,  after  a careful 
examination,  to  puncture  it,  in  order  to  ascertain  the  nature  of  the  substance 
within.  He  and  I concurred  in  the  opinion  that  the  tumour  consisted  of  a 
morbid  alteration  of  the  clitoris,  whose  praeputium,  as  before  remarked,  was 
seen  ascending  as  a crescentic  fold  on  the  sides.  It  was  not  skin  merely, 
but  half  skin  and  half  genito-urinary  mucous  tissue,  containing  a fluid  of 
considerable  consistence. 


OF  THE  FEMALE  URETHRA. 


85 


Dr.  Norris  plunged  a common  lancet  into  the  lower  end  of  the  tumour, 
and  the  instrument  gave  issue  to  a thick,  blackish  fluid,  of  the  consistence 
of  tar  or  thick  molasses,  perfectly  inodorous,  and  clearly  consisting  of  blood 
preserved  within  the  sac  from  the  very  commencement  of  the  disease,  four- 
teen years  before.  She  scarcely  felt  the  puncture.  The  whole  of  the  dark 
fluid  came  slowly  away,  as  from  a single  sac  without  cells  or  compartments, 
leaving  the  tumour  shriveled  and  looking  like  a shrunken  scrotum,  to  the 
great  relief  of  the  poor  woman,  who  had  been  much  annoyed  by  so  strange 
an  appendage.  The  quantity  withdrawn  was  estimated  to  be  twenty-two 
fluid  ounces.  No  evil  consequences  followed,  and  the  poor  woman  was 
not  in  the  least  incommoded  by  the  operation. 

There  could  not  rest  a doubt  upon  the  mind  as  to  the  seat  of  the  malady — 
it  was  a clitoris  converted  into  a cyst.  What  is  wonderful,  is  that  the  fluid 
should  have  remained  so  many  years  locked  up  within  the  clitoris,  without 
becoming  in  the  least  degree  offensive,  and  undergoing  no  other  change 
than  that  which  blood  undergoes  when  detained  for  a long  time  within  a 
reproductive  tissue — as  in  the  case  of  atresia  of  the  vagina.  The  liquid  is 
of  the  same  nature  as  that  I have  seen,  on  different  occasions,  from  atretism 
of  the  vagina,  where  the  catamenial  fluid  had  been  long  detained  in  the 
womb. 

I beg  leave  to  call  the  attention  of  the  reader  to  this  most  remarkable  phy- 
siological fact;  and  to  say  that,  so  far  as  my  knowledge  extends,  there  is  no 
example  of  blood  detained  for  months  and  years  in  cavities,  without  under- 
going decomposition,  except  when  it  is  detained  within  the  generative 
tissues.  The  blood  detained  in  aneurisms  is  wholly  different  from  the 
specimens  to  which  I allude.  In  this  case  the  whole  of  the  genitalia  were 
healthy  and  in  an  active  state  of  vitality;  with  the  sole  exception  of  this 
altered  clitoris  and  nymphae,  with  their  prosputium  or  hood.  ' 

Monday,  Sept.  21,  1844.  I examined  the  case  to-day;  the  tumour  is  form- 
ing again,  and  now  contains  some  six  or  eight  ounces  of  the  fluid.  I shall 
refer  to  this  case  again,  in  a note  to  M.  Colombat’s  article  on  hysteria. — M/] 

IMPERFORATION  AND  STRICTURE  OF  THE  FEMALE  URETHRA. 

Although  imperforation  of  the  meatus  urinarius  is  generally  a con- 
sequence of  the  complete  union  of  the  labia,  it  may  yet  sometimes 
exist  per  se,  and,  in  this  case,  the  orifice  of  the  urethra  is  stopped  by 
a thin  and  delicate  membrane,  which,  nevertheless,  is  strong  enough 
to  prevent  the  escape  of  the  urine. 

The  existence  of  such  a case  ought  to  be  suspected  where,  the 
labia  not  cohering,  the  napkins  of  the  infant  are  found  not  to  be 
wetted  with  the  usual  discharge  from  the  bladder,  and  where,  after 
discharging  all  the  meconium,  it  still  continues  to  cry  and  to  strain 
without  effect.  To  these  symptoms  should  be  added  the  gradual 
enlargement  of  the  hypogastric  region,  which  is  tense,  painful,  resist- 
ing and  rounded,  and  exhibits  a much  less  perceptible  prominence. 

The  membrane  which  prevents  the  urinary  discharge  may  be  con- 
fined to  the  orifice  of  the  canal,  or  may  extend  to  a greater  depth 


SG  OBTURATION  OF  THE  FEMALE  URETHRA.  . 

within  it.  In  the  first-named  case,  which  is  the  most  common  and 
the  most  easily  remedied,  the  membrane  swells  outwards  with  each 
effort,  and  even  with  every  cry  of  the  infant; — in  the  second  case, 
that  is,  where  the  imperforation  affects  a great  part  of  the  tube,  no 
membrane  can  be  discerned,  and  the  operation  becomes  difficult  and 
even  very  dangerous. 

When  the  canal  is  stopped  only  at  the  vulvar  orifice,  all  that  is 
necessary  for  opening  a passage  for  the  urine  is  to  puncture  the 
membrane  spoken  of  with  the  point  of  a narrow  bistoury,  and  to 
leave  a small  catheter  in  the  urethra  for  a few  days.  It  ought  to  be 
added  that  the  latter  process  is  not  to  be  considered  indispensable, 
but  seems  to  us  useless,  because  the  contact  of  the  urine  and  its  fre- 
quent passage  would  generally  suffice  to  prevent  the  union  of  the 
divided  parts. 

By  means  of  an  abnormal  orifice  at  the  umbilicus,  which  is  more 
frequently  met  with  in  female  than  in  male  children,  nature  some- 
times obviates  imperforation  of  the  urethra.  Immediately  after  birth 
the  bladder,  which  is  still  almost  wholly  above  the  brim  of  the  pel- 
vis, approaches  the  umbilicus,  and  the  incomplete  obliteration  of  the 
organ  facilitates  the  establishment  of  this  supplemental  mode  of  ex- 
cretion. 

When  this  anomaly  is  met  with  in  a young  infant,  an  incision,  as 
already  directed,  should  be  made  into  the  obturator  membrane  at  the 
mouth  of  the  urethra,  after  which  a catheter  should  be  left  for  some 
time  in  the  bladder,  in  order  to  restore  to  the  fluid  its  natural  course. 
The  same  treatment  is  applicable  at  any  age. 

Barthelemi  Cabrol,  an  able  surgeon  at  Gaillac,  who  was  appointed 
by  Henry  IV.,  Demonstrator  of  Anatomy  at  the  School  of  Montpel- 
lier, informs  us*  that  a girl,  eighteen  years  of  age,  had  the  urethra 
stopped  by  a membrane,  so  that  the  urine  passing,  it  is  probable, 
along  the  urachus,  escaped  at  the  navel,  which  projected  about  four 
inches  and  exhaled  an  intolerable  stench.  In  treating  the  case,  Ca- 
brol first  made  an  incision  through  the  membrane  that  had  closed 
the  urethra,  and  then  introduced  a leaden  canula  into  the  bladder  in 
order  to  give  free  course  to  the  urine.  On  the  next  day,  having 
thrown  a strong  ligature  about  the  projecting  portion  of  the  navel,  he 
cut  off  the  protuberance  beyond  the  ligature.  He  touched  the  spot 
with  the  actual  cautery,  and  when  the  eschar  fell  off  he  dressed  the 
surface  with  desiccatives,  and  obtained  a complete  cicatrization  in 
twelve  days.  In  such  a case  the  same  treatment  ought  to  be  adopted, 
with  exception  of  the  cautery,  which  is  unnecessary,  and  which  terri- 
fies the  patient  to  no  purpose. 

Where  the  orifice  exhibits  only  a narrow  opening  through  which 
the  urine  escapes  with  difficulty,  it  is  a case  of  stricture  of  the  ure- 
thral orifice,  and  not  one  of  imperforation  of  the  canal.  In  this  case 
the  orifice  should  be  fitly  enlarged  by  means  of  a narrow  bistoury 
and  a grooved  director. 

[I  cannot  avoid  entering  my  protest  against  this  doctrine,  for  it  is  indu- 
bitable that  in  all  such  cases,  when  the  most  delicate  probe  can  be  made  to 


Observat.  Anatom.,  23. 


FAULTY  CONFORMATION  OF  THE  VAGINA. 


87 


pass,  the  difficulty  is  easily  to  be  overcome  by  the  daily  use  of  the  bougie, 
beginning  with  one  of  a small  size,  and  gradually  enlarging  it  till  the  orifice 
has  acquired  a proper  magnitude.  It  is  not  necessary  to  do  more  than  pass 
the  bougie  through  the  stricture,  to  retain  it  there  about  a minute  and  no 
longer,  when  it  will  be  found  that  a larger  one  will  be  admitted  on  the  same 
terms  the  next  day ; and  so  on  until  one  sufficiently  large  can  be  passed. 
Its  use  repeated  afterwards  from  time  to  time,  say  once  in  two,  three  or  four 
weeks,  will  perfect  the  cure. — M.] 

Where  the  constriction  or  occlusion  of  the  canal  extends  through- 
out a great  part,  of  its  tractus,  and  especially  where  the  urine  finds 
no  other  outlet,  the  child  must  inevitably  perish  if  not  opportunely 
succoured,  and  even  here  there  is  but  one  means  of  rescue,  and  that 
by  a very  doubtful  operation:  I mean  the  puncture  of  the  bladder 
by  means  of  a bistoury  or  a delicate  trocar,  which  should  be  plunged 
into  the  point  where  the  orifice  of  the  urethra  ought  to  be,  and  thence 
conducted  to  the  cavity  of  the  bladder.  Should  the  fear  of  giving  an 
erroneous  direction  to  the  instrument  or  any -other  motive  lead  to  a 
rejection  of  this  operation,  then  there  should  be  no  hesitation  as  to 
making  a puncture  of  the  bladder  through  the  vagina  or  rectum,  and 
should  the  structure  of  those  passages  be  of  such  a nature  as  to 
oppose  these  methods,  recourse  might  be  had  to  a puncture  above 
the  symphysis  pubis. 

It  is  to  be  confessed  that  in  these  cases  the  infants  are  generally 
lost,  even  where  we  have  succeeded  in  re-establishing  the  course  of 
the  urine  by  any  of  the  methods  just  pointed  out. 

In  order  to  conclude  what  we  had  to  say  upon  the  subject  of  pre- 
ternatural conformation  of  the  vulva  and  its  dependencies,  we  must 
add,  that  although  the  labia  pudendi  may  possibly  be  wanting  as  a 
congenital  defect,  they  may  also  be  destroyed  by  gangrene  or  cor- 
roding ulcers.  In  the  latter  case  the  lesion  is  often  accompanied  by 
occlusion  of  the  vagina  or  the  meatus  urinarius,  which  will  require 
the  treatment  we  have  already  pointed  out. 

FAULTY  CONFORMATION  OF  THE  VAGINA. 

The  deformities  of  the  vagina,  whether  congenital  or  accidental, 
that  are  susceptible  of  cure  by  surgical  treatment,  are,  imperforation, 
obliteration,  obturation,  congenital  narrowness,  and  stricture  or  con- 
traction. 

IMPERFORATION  OF  THE  VAGINA. 

Imperforation  of  the  vagina  has  been  noticed  by  several  of  the 
ancient  medical  writers.  Hippocrates  speaks  of  it  in  his  first  book 
of  the  Diseases  of  Women , but  points  out  no  treatment  for  the  case. 
Aristotle,  who  was  preceptor  to  Alexander  the  Great,  and  who  lived 
three  centuries  before  the  Christian  era,  teaches  us  that  some  girls 
have  the  vagina  closed  at  birth  and  until  the  period  for  men:'  lation ; 
that  the  blood  then  gradually  secreted  gives  rise  to  violent  pains  that 
never  cease  until  it  has  either  forced  a passage  for  itself,  or  until  one 
has  been  formed  for  it  by  artificial  means. 


8S 


IMPERFORATION  OF  THE  VAGINA. 


Ill  some  instances  no  relief  has  been  obtained  until  death  super- 
vened, in  consequence  of  the  violence  by  which  the  passage  has  been 
produced,  or  of  the  impossibility  of  establishing  one. 

Imperforation  of  the  vagina  has  also  been  noticed  by  a great 
number  of  other  authors,  among  whom  we  may  mention  Celsus,* 
Soranus  of  Ephesus, t Moschion,±  Roonhuysen,§  Benevenius.||  Ca- 
brol,1T  J.  Fabricius  ab  Acquapendente,**  Fabricius  Hildanus,tt 
Schenk, f±  Solingen,§§  Meeckren,||||  Mauriceau,1F1[  Ruysch,***  Savi- 
ard,ttt  and  many  others  whose  names  it  would  be  tedious  to  cite. 

The  imperforation  of  the'  vagina  that  consists  in  the  occlusion  of 
the  anterior  orifice  of  the  canal,  may  be  either  complete  or  incom- 
plete, accidental  or  congenital ; it  may  be  due  either  to  the  hymen  or 
to  some  other  fold  of  the  mucous  membrane,  or  to  the  presence  of 
cellular  or  cellulo-fibrous  bands  crossing  in  different  directions,  and 
found  at  different  distances  from  the  os  magnum. 

Complete  imperforation  is  generally  not  discovered  until  puberty, 
or  at  the  commencement  qf  the  mensual  office.  The  young  female 
is  at  first  subject  to  all  the  symptoms  that  precede  and  accompany 
menstruation,  except  that  she  perceives  no  discharge  of  blood.  The 
health  that  had  before  been  good,  suddenly  becomes  disordered 
without  any  evident  cause  for  the  change.  The  abdomen  becomes 
the  seat  of  disorders  previously  not  known  to  the  patient  ; the  hypo 
gastrium  becomes  more  and  more  painful  and  takes  on  a gradual 
and  uniform  enlargement ; the  patient  feels  pain  in  the  loins,  weight 
within  the  pelvis,  spasms,  suffocation,  intense  cephalalgia;  and,  in 
fine,  a variety  of  disorders  the  seat  of  which  is  clearly  in  the  gene- 
rative organs,  and  the  origin  of  which  is  at  first  always  enveloped  in 
obscurity.  All  these  symptoms,  which  undergo  a partial  diminution 
in  the  course  of  a few  days,  augment  in  violence  with  each  return  of 
them.  The  abdomen  grows  gradually  larger,  and  sometimes  acquires 
a size  equal  to  that  which  it  attains  in  an  advanced  stage  of  preg- 
nancy, most  of  the  symptoms  of  which  are  now  found  to  be  present, 
such  as  swelling  of  the  breasts,  nausea,  vomiting,  disgust,  queer 
appetite,  &c.  The  symptoms  in  the  case  so  closely  resemble  those  of 
gestation,  that  learned  physicians  have  pronounced  it  to  be  preg- 
nancy, though  the  patient  were  still  a virgin.  Samples  of  this  kind 
are  given  by  J.  Wierus,if±  B.  Cabrol,§§§  Fab.  Hildanus,||||||  J.  Mu- 
ratt,1HI1F  and  some  of  the  modern  authors  who  cite  cases  of  the  kind. 

In  order  to  avoid  the  distressing  results  of  such  mistaken  diagnosis 
and  remove  all  doubts  on  the  subject,  it  is  merely  necessary  to  reflect 

* Corn.  Celsus  de  Medjcina,  lib.  vii.  cap.  28. 

t De  Utero,  et  Muliebri  Pudendo.  Libel,  et  Aetius,  lib.  xvi.  cap.  95. 

* Gynmciorum  de  Mulier.  affect:  et  Morb.,  part  i.  cap.  3.  # 

4 Lib.  ii.  De  Clausura  Uteri.  ||  See  Abdilis  Morb.  Causis,  cap.  28. 

« Observ.  Anat.,  23.  '*  In  Operat.  Chirurg.  de  Hymene  Imperforato. 

ff  Centur.  iii.,  obs.  60.  it  Lib.  iv.  De  Part  Genital. 

§§  In  Observ.  v.  ||!|  Observ.  Chirurg.  55. 

Observat.  sur  les  Malad.  des  Femmes.  ***  Observ. Chirurg.  32. 

Iff  Observat.  Chirurg.  &c. 

De  Dcemonum  Praesiigiis  et  Incantationibus,  lib.  iii.  cap.  38. 

§§§  Observ.  Medicin.,  obs.  23.  Ilii  l Centur.  iii.,  observ.  60.  exemp.  3. 

iii  Ephem.  Curios.  Natur.  decur.  ii.,  anno.  3.  observ.  151. 


IMPERFORATION  OF  THE  VAGINA. 


89 


that  where  the  development  of  the  abdomen  arises  from  menses 
retained  in  the  womb  and  vagina,  in  consequence  of  congenital 
imperforation  or  accidental  obliteration  of  the  vagina,  the  develop- 
ment takes  place  at  intervals,  and  by  periods  that  correspond  to  the 
mensual  epochs,  that  is  to  say,  once  a month. 

As  each  menstruation  goes  to  increase  the  pre-existing  collection, 
the  accumulation  of  blood  becomes  enormous,  compressing  with  in- 
creasing violence  not  only  the  parts  above  that  are  in  the  vicinity  of 
the  enlarged  womb,  but  also  all  the  contents  of  the  excavation  of  the 
pelvis,  as  the  rectum,  the  bladder,  the  sacral  plexus,  the  sciatic  nerves, 
&c.  It  is  to  this  very  compression  that  we  have  to  attribute  not  only 
the  dysuria  and  the  difficult  defecation,  but  also  the  engorgement, 
cramps  and  swellings  of  the  lower  extremities,  the  weight  at  the  rec- 
tum and  perineum,  and,  indeed,  the  uneasy  feeling  of  imperforate 
females,  principally  in  the  pelvic  region,  felt  in  walking  and  standing. 
Hippocrates*  speaks  of  a young  girl  who  became  lame  from  the 
accumulation  of  blood  in  the  vagina,  for  which  there  was  no  means 
of  escape,  and  which  produced  compression  of  the  sacral  nerves. 
Morgagni  ( De  Sec/,  et  Caus.  Marb.)  asserts  that  atresia  is  capable 
of  producing  insanity;  for  other  authors  have  noticed  cases  of  con- 
vulsions, hysteria  and  delirium  proceeding  from  the  same  cause.  In 
a case  of  retention  of  the  menses  from  complete  imperforation,  De- 
haent  discovered  that  the  Fallopian  tubes,  from  being  distended  with 
blood,  had  given  way  and  occasioned  a fatal  effusion. 

In  some  rare  cases,  the  blood  effused  at  each  menstruation  has. 
been  absorbed  so  as  to  disappear  during  the  interval;  the  abdomen, 
which  had  become  hard  and  swollen  for  several  days,  has  soon 
returned  to  its  natural  size.  Patients  exhibiting  this  double  anomaly, 
both  physiological  and  anatomical,  may  resist  the  evil  for  a long 
time,  but  with  an  ever-doubtful  health. 

In  certain  women  with  imperfect  sexual  organs,  nature  affords  a 
substitute  for  the  menstruae,  by  means  of  periodical  haemorrhages 
and  engorgements,  at  the  anus,  the  lungs,  the  breasts,  the  stomach, 
the  nostrils,  the  ears,  the  tegumentary  surface,  &c. 

A vaginal  imperforation  is  not  invariably  followed  by  the  conse- 
quences we  have  spoken  of.  These  consequences  may  in  some  indi- 
viduals never  be  made  manifest,  though  the  menstruation  may 
wholly  fail,  and  even  not  find  a substitute  in  any  other  evacuation 
of  blood.  This  happens  in  those  cases  where,  together  with  imper- 
forate vagina,  there  is  absence  of  the  womb  itself.  Such  a state  of 
things  ought  to  be  inferred  in  women  who  have  passed  the  period 
for  the  appearance  of  the  catamenia,  when  the  genital  apparatus 
ordinarily  enters  upon  the  exercise  of  its  exhalent  functions  : cases 
of  the  kind  are  to  be  found  in  the  annals  of  the  science  of  medicine. 

In  general,  the  diagnosis  of  vaginal  imperforation  is  quite  easy  to 
be  made,  and  an  attentive  examination  of  the  genitalia  suffices  to 
dissipate  all  doubt  upon  this  rare  affection. 

We  may  ascertain  that  the  obstacle  that  closes  the  passage  is 


* De  Morb.  Mulierum. 


f Ratio  Medendi,  par.  6. 


90 


IMPERF  ORATION  OF  THE  VAGINA. 


merely  the  hymen,  whenever  we  discover  between  the  labia  a hemi- 
spherical tumour  of  a livid  or  bluish  colour,  soft  and  fluctuating,  and 
rendered  salient  by  the  weight  of  the  contained  blood.  In  such  a 
case,  most  authors  have  recommended  that  with  a view  to  destroy 
the  obstacle,  we  should  plunge  a straight  bistoury  into  the  centre  of 
the  tumour  so  as  to  make  a crucial  incision,  the  operation  being 
completed  by  afterwards  removing  the  flaps  or  angles  by  means  of 
curved  scissors  and  a forceps.  A tent  of  lint  spread  with  cerate  and 
introduced  betwixt  the  edges,  suffices,  in  a majority  of  cases,  to  pre- 
vent the  reunion  of  the  divided  surfaces. 

In  cases  of  occlusion  caused  by  the  hymen,  Celsus*  recommends 
the  incision,  which  he  describes  as  follows.  Si  niembrana  orx  vulvx 
opposita  est....oporlet  autem  membrnnam  duabus  lineis,  infer  se 
transversis  incidere  ad  similitudinem  lit  ter  x X,  magna  cura  habit  a 
ne  urinx  iter  violetur , deinde  undiqne  earn  membranym  excidere. 

Avicennat  directed  that  the  membrane  should  be  ruptured  with 
the  point  of  the  finger  covered  with  a piece  of  linen,  and  Mauriceau 
advised  that  it  should  be  torn  by  means  of  the  finger  nail. 

The  mode  of  treating  retention  of  the  menses  from  imperforate 
hymen  by  a crucial  incision,  is  often  followed  by  serious  conse- 
quences, for  the  sudden  escape  of  the  fluid  renders  it  impossible  for 
the  parietes  of  the  womb,  too  suddenly  emptied,  to  contract  imme- 
diately, a circumstance  that  often  gives  rise  to  fatal  inflammation, 
and  to  fever  of  a bad  character. 

In  order,  as  far  as  possible,  to  obviate  the  bad  consequences  of  the 

operation  in  question,  and  espe- 
cially with  a view  particularly  to 
preserve  the  hymen,  to  which  is 
attached  a great  moral  import- 
ance, we  propose  the  following 
mode  of  operation,  which  is  equal- 
ly simple  and  easy  of  perform- 
ance, and  in  doing  which  we  need 
not  entertain  the  least  fear  of 
wounding  the  vagina  itself. 

Having  placed  the  woman  in 
the  situation  required  for  the  use 
of  the  speculum,  let  an  assistant 
separate  the  labia  and  nymphse, 
and  then  seizing  the  centre  of  the 
tumour  with  a tenaculum,  or  what 
is  still  better,  with  broad  forceps, 
the  membrane  is  pulled  outwards 
and  a proper  portion  of  it  removed 
by  cutting  it  from  below  upwards 
with  a scissors  curved  on  the  side, 
or  what  answers  better  still,  with 
our  scissors  emporle  piece , ( vid . 
figure ,)  for  the  extirpation  of  the 

\ Avicenna,  lib.  iii.,  scu.  21.  tr.  4.  cap.  1. 


* Celsus  de  Med.,  lib.  vii.  cap.  29. 


I 


IMPERFOItATION  OF  THE  VAGINA.  91 

frasnum  of  the  tongue.'*  The  aperture  produced  in  this  manner 
gives  a small  oval  circumference,  which  nearly  resembles  the  natural 
orifice  of  the  hymen,  admits  of  a gradual  evacuation  of  the  retained 
blood,  and  of  a regular  and  slow  return  of  the  distended  organs  to 
their  natural  dimensions  without  too  sudden  a void.  In  this  way 
the  admission  of  air  in  lesser  quantity  and  less  suddenly,  does  not  so 
readily  determine  the  attack  of  intense  and  often  fatal  inflammation 
that  is  apt  to  follow  the  common  mode  of  operating. 

In  some  cases  it  is  found  that  there  are  two  membranes,  the  one 
placed  above  the  other.  Fred.  Ruyscht  published  a case  in  which 
he  was  obliged  to  make  an  incision  into  each  of  two  membranes. 
Thomas  Willis  states  that  he  was  called  to  a woman  upon  the  point 
of  being  confined,  and  who  had  had  severe  pains  for  three  days 
preceding  his  visit.  Upon  carefully  examining  the  genital  organs, 
he  discovered  a membrane  that  adhered  to  the  circumference  of 
the  vulva,  and  that  prevented  the  delivery  of  the  foetus.  Having 
made  an  incision  into  it,  and  finding  that  the  delivery  still  did  not 
take  place,  he  again  examined  the  parts,  and  found  that  there  was 
another  membrane  situated  at  a greater  depth  within  the  passage, 
and  which  detained  the  child  above  it.  Having  removed  this  obsta- 
cle, the  labour  was  soon  and  happily  terminated. 

In  some  cases  a membranous  band  of  greater  or  less  thickness 
divides  the  orifice  of  the  vagina  into  two  small  lateral  apertures ; and 
it  must  doubtless  be  this  sort  of  fleshy  column  that  induced  Mor- 
gagni, Valsalva  and  other  authors  to  designate  the  hymen  by  the 
descriptive  term  columna  virginiiatis — pillar  of  virginity.  This 
band,  in  some  specimens,  is  traversed  horizontally  by  one  or  more 
bands  producing  a cribriform  diaphragm,  as  in  cases  stated  by  Fab. 
HildannSjf  Viardel§  and  Prof.  Flamand.|| 

[Some  years  since  I was  invited  by  Dr.  John  Ruan  to  visit  a patient  with 
him,  who  was  in  a severe  labour,  in  which  considerable  delay  and  difficulty 
were  experienced.  I found  that  the  vagina  was  divided  into  two  lateral 
halves  by  a septum,  which  extended  from  the  external  orifice  or  os  magnum 
to  near  the  uterine  extremity  of  the  canal,  and  that  the  head  of  the  child  was 
pressed  into  the  right  one,  compressing  the  other  against  the  left  side  of  the 
pelvis.  It  was  agreed  that  I should  deliver  her  with  the  forceps,  which  I 
accordingly  did;  and  she  gave  birth  to  a healthy  infant  without  accident  or 
any  untoward  result.  As  the  malconformation  had  presented  so  rare  a 
specimen,  I prevailed  upon  her  to  allow  me  to  examine  the  parts  after  her 
recovery,  which  enabled  me  to  discover  that  the  septum  had  not  given  way 
at  all  during  the  distension  of  the  right  canal.  I had  no  reason  to  suppose 
that  the  septum  was  repeated  in  the  uterus. — M.] 

* This  instrument,  Fig.  11,  described  and  figured  in  our  Traite  du  Begaiement, 
and  in  La  Revue  Medicale,  will  also  be  represented  in  our  Dictionnaire  Historique  et 
Iconographique  de  toutes  les  Operations  et  les  Instruments  et  Appareils  de  la  Chi- 
rurgie,  Ancienne  et  Moderne,  with  1500  figures,  4 vols.  8vo.  Paris,  1836-7. 

f Fred.  Ruysfch,  Obs.  Chir.  22  and  32. 

* Hier.  Fab.  Hildanus,  cent.  iii.  obs.  60. 

§ Viardel,  Observ.  sur  la  Prat,  des  Accouchements,  p.  167. 

||  Disp.  Inaug.  du  Doct.  Villette,  annee,  1824. 


92 


IMPERFORATION  OF  THE  VAGINA. 


There  have  been  examples  of  women  labouring  under  imperfora- 
tion,  (and  their  ignorant  physicians  have  agreed  with  them,)  who 
have  mistaken  the  meatus  urinarius  for  the  orifice  of  the  vagina, 
supposed  to  be  contracted,  and  upon  dilating  it  as  far  as  possible, 
have  made  it  subserve  the  uses  of  the  latter,  thus  giving  rise  to 
incurable  incontinence  of  urine  and  other  consequences.* 

Dr.  Villette  states,  in  his  Inaugural  Essay , that  a lady  of  Stras- 
bourg, was  under  the  care  of  M.  Chevalier  during  her  accouchement. 
Upon  performing  the  Touch  he  was  surprised  to  find  a polished  orifice. 
In  the  state  of  uncertainty  in  which  he  was  placed,  he  called  in  Prof. 
Flamand,  who  required  a close  examination  of  the  parts;  but  what 
was  his  surprise  to  find  the  urethra  sufficiently  large  to  admit  the 
index  finger  in  Touching.  At  the  orifice  there  was  a cribriform 
lamella,  through  which  the  mensual  discharge  escaped.  The  mem- 
brane was  excised,  and  the  labour  brought  to  a successful  conclusion. 

When  the  membrane  that  closes  the  vagina  is  very  thick,  the 
finger  pressed  against  it  meets  with  more  considerable  resistance, 
and  it  is  difficult  to  discover  the  fluctuation,  which  is  quite  manifest 
where  the  membrane  is  thin.  The  proper  mode  of  proceeding  in 
such  a case  consists  in  making  sure,  by  means  of  a sound,  as  to  the 
disposition  of  the  bladder,  and  in  exploring  the  rectum  by  the  touch. 
Then  after  the  labia  are  separated  by  an  assistant,  a crucial  incision 
is  made  with  a straight  bistoury  conducted  by  the  index  finger,  and 
wrapped  in  a bit  of  linen  to  within  six  lines  of  the  point : [a  bit  of 
adhesive  plaster  is  a convenient  guard  for  the  edge. — M.]  When 
the  crucial  incisions  are  completed,  the  flaps  ought  to  be  taken  off  as 
has  been  already  mentioned,  and  the  orifice  kept  open  by  a dossil  of 
lint,  spread  with  cerate,  and  to  which  is  attached  a piece  of  thread ; 
the  lint  to  be  renewed  daily.  The  blood  that  escapes  is  generally 
viscous,  black  and  foetid  ; it  escapes  with  violence  upon  making  the 
puncture,  and  then  concludes  by  escaping  drop  by  drop. 

To  assist  in  cleansing  the  genital  cavities  of  the  patient,  and  par- 
ticularly to  get  off  the  coagula,  which,  by  remaining,  might  provoke 
an  attack  of  inflammation,  a free  use  ought  to  be  made  of  emollient 
lotions,  and  subsequently  of  detergent  and  slightly  resolvent  or  even 
antiseptic  injections,  according  to  the  circumstances  and  indications  of 
the  particular  case. 

Where  the  vaginal  partition  is  fleshy,  Celsust  advises  us  to  make 
a longitudinal  incision,  and  then  taking  hold  of  the  edge  with  a for- 
ceps, to  cut  a strip  from  it.  He  next  placed  in  the  wound  an  oblong 
tent  moistened  with  vinegar,  and  over  that  applied  a bit  of  wool  in 

* In  the  Journal  de  Medecine,  published  at  Orleans,  by  M.  Latour,  61s,  and  in  the 
article  lmpuismnce  of  the  Did.  des  Sci.  Med.,  may  be  found  a case  related  by  Mor- 
gagni. (Lettre  40,  n.  12.)  A peasant,  in  the  vicinity  of  Orleans,  had  misinterpreted  a 
metaphorical  expression  that  had  fallen  from  his  confessor,  who  attributed  the  ste- 
rility of  his  marriage  to  his  not  being  dans  la  bonne  voie,  and  was  so  stupid  as  to  sub- 
stitute the  urethra  for  the  vagina.  The  beginning  was  difficult,  but  by  means  of  pro- 
gressive dilatation,  effected  by  divers  mechanical  aids,  he  attained  his  object,  and 
remained  for  some  time  under  his  mistake,  until  the  inconvenience  of  her  urine  and 
other  symptoms  compelled  his  wife  to  call  in  the  aid  of  a physician. 

f Qon*  Cels,  de  Med.,  lib.  vii.  cap.  28. 


IMPERFORATION  OF  THE  VAGINA. 


93 


the  grease,  soaked  also  with  vinegar,  the  whole  being  kept  in  situ  by 
means  of  a proper  bandage.  On  the  third  day  he  removed  the  dress- 
ings, and  for  the  rest  of  the  treatment  acted  as  in  ordinary  wounds. 
When  the  cut  began  to  heal,  he  introduced  a leaden  canula  covered 
with  a substance  promotive  of  cicatrization,  and  applied  externally 
the  same  medicament  until  the  cure  was  perfect. 

For  the  removal  of  atresia,  resulting  from  the  presence  of  a thick 
ipembrane,  Hippocrates*  and  other  authors  have  proposed  the  use 
of  caustics.  Bauhint  made  use  of  caustics  in  a case  which  termi- 
nated fatally  after  the  fall  of  the  eschar.  A.  Paref  and  his  pupil 
Guillemeau  recommended  an  incision  from  above  downwards:  others 
think  it  better  to  make  an  oblique  one,  in  order  to  avoid  the  risk  of 
wounding  the  urethra.  The  celebrated  Dupuytren,  whose  practical 
opinions  have  such  great  weight,  advised  that  the  incision  should  be 
made  from  above  downwards,  and  especially  that  the  division  should 
be  carried  to  the  very  lower  edge  of  the  membrane,  for  the  purpose 
of  obviating  the  stasis  of  the  blood  and  mucus  behind  it;  and  par- 
ticularly to  spare  her  the  disagreeable  and  inconvenient  necessity  of 
using  vaginal  injections. 

Where  the  obturating  membrane  is  situated  very  deep  in  the  pass- 
age, the  vagina  generally  preserves  its  ordinary  dimensions  above 
the  obstacle  ; but  it  may,  from  the  prolonged  retention  of  the  menses, 
acquire  an  unnatural  magnitude  at  its  upper  part.  In  order  to 
destroy  the  membrane  in  such  a case,  we  must  expose  it  and  protect 
the  walls  of  the  vagina  by  means  of  a speculum,  then  make  a crucial 
incision,  the  cuts  being  oblique  in  order  to  avoid  injury  to  the  blad- 
der or  rectum.  The  four  flaps  should  then  be  removed  as  already 
advised. 

In  the  case  which  is  not  very  unfrequently  observed,  where  the 
membrane,  being  of  a thick  and  fleshy  nature,  forms  an  annular 
band  within  the  vagina,  and  has  only  a very  small  opening,  the 
menstrual  fluid  escapes,  but  only  drop  by  drop.  Such  cases  have 
been  noted  by  Daniel  Sennertus  of  Breslau, § Chambon,||  A.  ParelF 
and  Prof.  Flamand.**  This  sort  of  dysmenorrhcea  always  occasions 
a state  of  tension  of  the  external  genitals,  and  a feeling  of  weight 
about  the  perineum  attended  with  pretty  severe  pains  in  the  hypo- 
gastrium,  and  an  unnatural  sensibility  of  all  the  organs  contained 
within  the  cavity  of  the  pelvis. 

The  mode  of  curing  this  anomaly,  which  is  prejudicial  to  the  con- 
gress and  to  conception,  consists  in  enlarging  the  opening  with  a 
probe-point  bistoury,  making  crucial  incisions  and  then  removing 
the  flaps,  and  afterwards  keeping  up  the  dilatation  with  a stout 
canula  or  any  proper  tent.  Before  resorting  to  an  operation,  Ave 
should  clearly  ascertain  that  the  occlusion  is  due  only  to  the  pre- 
sence of  a membrane,  which  may  be  done  by  introducing  a sound 
into  the  little  opening  which  will  be  found  at  some  point  upon  the 

* Lib.  de  Sterilitat.  et  lib.  ii.  De  Morb.  Mul.  f Anat.,  liv.  i.  chap.  39. 

i Liv.  iv.  chap.  59.  p.  998.  § De  Morb.  Mulierum,  lib.  iv.  part  i. 

||  Malad.  des  Filles,  liv.  i.  chap.  2.  p.  51.  ^ Pare,  liv.  xxiv.  chap.  19. 

**  Lecons  Orales  ala  Faculte  de  Strasbourg. 


94 


CONGENITAL  NARROWNESS  OF  THE  VAGINA. 


surface  of  the  obstacle,  above  or  beyond  which  Ihe  end  of  the  sound 
ought  to  be  movable  freely ; but  in  order  that  the  operation  may  be 
safe,  even  if  the  occlusion  be  of  the  sort  in  question,  the  bladder  and 
rectum  should  both  have  been  emptied  before  the  incisions  are  made; 
since  the  matters,  whether  solid  or  liquid,  contained  in  them,  might, 
by  rendering  them  more  salient,  expose  them  to  injury  from  the 
edge  of  the  scalpel. 

OF  CONGENITAL  NARROWNESS  OF  THE  VAGINA. 

Narrowness  of  the  vagina  is  a congenital  affection,  whereas  con- 
striction and  obliteration  of  the  passage  may  depend  upon  various 
accidental  causes  that  we  shall  treat  of  in  a subsequent  page. 

Instances  have  been  met  with  in  which  the  diameter  of  the  vagina 
did  not  exceed  five  or  six  lines.  This  original  deformity,  like  those 
that  we  have  already  spoken  of,  obviates  the  accomplishment  of  the 
purposes  for  which  it  was  designed  by  nature.  In  case  that  strong 
and  repeated  efforts  should,  during  the  congress,  be  made  to  over- 
come the  obstacle,  the  consequences  would  be  a considerable  inflam- 
mation and  contusions  productive  of  discharges  and  the  symptoms 
of  strangury,  leading  to  suspicions  of  venereal  taint.  Under  such 
circumstances,  after  having  removed  the  inflammation  by  the  use  of 
topical  emollients  and  other  antiphlogistic  measures,  such  as  venesec- 
tion, leeches,  baths,  narcotics  and  antispasmodics,  and  diluting  and 
cooling  drinks,  we  should  endeavour  to  dilate  the  vaginal  parietes  by 
the  employment  of  such  dilaters  as  may  expand  after  their  applica- 
tion, such,  for  example,  as  sponge  tents,  bits  of  gentian  root  covered 
with  cerate,  large  bougies  and  cylindrical  caoutchouc  pessaries,  to  be 
gradually  increased  in  size  until  the  vagina  shall  have  acquired  its 
normal  dimensions. 

With  the  same  view,  Hippocrates  made  use  of  a tin  tube.  Without 
following  the  recommendation  thus  given  by  the  father  of  medicine, 
we  are  of  opinion  that  use  might  advantageously  be  made  of  a sort 
of  cylindrical  dilater,  composed  of  three  or  four  pieces  joined  by 
hinges,  and  made  so  as  to  move  and  separate  more  or  less  distantly 
by  means  of  a screw,  adjusted  like  that  in  our  jointed  speculum 
and  which  is  figured  in  this  work  at  page  66. 

As  the  narrowness  of  the  vagina  may  affect  only  a portion  of  the 
tube,  the  first  thing  to  be  done  is  to  ascertain  its  situation  and  extent 
by  using  a sound,  which  should  be  see-sawed  in  every  direction  if 
possible.  If,  upon  its  introduction,  it  be  found  confined  as  to  its 
movements,  and  particularly  if  the  end  of  it  cannot  be  made  to  move 
freely,  we  may  be  sure  that  the  narrowness  extends  throughout  the 
entire  length  of  the  canal;  but,  on  the  other  hand, if  the  see-saw 
motion  of  the  end  of  the  sound  is  free,  we  shall  have  to  do  with  a 
narrowness  extending  only  a few  lines  of  the  length  of  the  vagina. 

Where  there  is  a want  of  development  of  the  vaginal  walls,  the 
internal  surfaces  have  a hard  feel  and  seem  to  be  fibrous  and  undi- 
latable.  For  the  purpose  of  promoting  their  amplification,  we  ought, 
to  the  use  of  the  dilaters,  to  add  that  of  injections  of  oil  and  muci- 


CONGENITAL  NARROWNESS  OF  THE  VAGINA. 


95 


lages,  of  topical  baths,  of  fumigations,  and  especially  the  frequent 
application  of  suppositories  of  beurre  de  cacao  introduced  within  the 
vagina. 

The  means  above  pointed  out  act  very  commonly  in  an  efficacious 
manner,  and  are  devoid  of  the  dangers  that  inevitably  ensue  from 
the  dilatation  of  the  part  procured  by  any  other  mode  of  proceeding. 
Besides,  if  the  success  obtained  in  this  way  be  not  always  perma- 
nent, we  have  it  in  our  power  to  repeat  the  treatment  if  necessary, 
without  any  inconvenience  and  without  compromising  the  lives  of 
our  patients. 

[In  three  cases  of  congenital  narrowness  of  the  vagina  that  have  fallen 
under  my  notice,  one  was  that  of  a lady  who  was  pregnant  at  the  seventh 
month,  and  in  premature  labour  when  I was  called  upon  to  see  her.  I was 
greatly  surprised,  upon  making  the  usual  examination,  to  meet  with  con- 
siderable difficulty  in  the  introduction  of  the  index  into  the  passage,  and  it 
was  not  without  some  time  and  a very  considerable  resistance,  that  1 at  last 
succeeded  in  carrying  the  finger  to  the  os  uteri,  which  was  already  some- 
what dilated.  The  lady,  who  was  young,  gave  birth,  after  many  hours  of 
severe  expulsive  action,  to  a dead  foetus  of  seven  months,  and  she  recovered 
of  the  effects  of  her  labour,  in  which  she  met  with  no  accident.  I cannot  but 
believe  that  she  conceived  without  a perfect  congress,  which  I deem  to  have 
been  impossible. 

In  another  case,  a lady  came  from  a distant  state ; she  had  been  several 
years  married,  and  many  and  various  efforts  had  been  made  to  relieve  her 
by  the  use  of  bougies,  without  any  success.  She  spoke  of  some  operation 
that  had  been  performed  with  the  bistoury,  the  nature  of  which  I could  not 
comprehend  from  her  description  of  it.  I saw  her  in  comps/ny  with  Dr. 
Horner,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.  The 
vagina  received,  with  some  pressure,  a full-sized  urethra  bougie,  and  it  was 
evident  that  the  narrowness  occupied  the  whole  extent  of  the  canal,  save  a 
small  part  of  the  upper  extremity  where  it  embraces  the  cervix  uteri.  The 
treatment  consisted  in  moderate  dilatations  with  the  bougie  at  first,  which 
was  followed,  in  a day  or  two,  by  bits  of  sponge  tent.  These  tents,  by 
their  expansion,  effected  a dilatation  sufficiently  great  to  admit  of  the  pass- 
ing of  the  index  readily  to  the  os  uteri.  When  the  passage  had  by  this 
means  been  considerably  enlarged,  the  inner  surface  of  the  vagina  was  dex- 
terously incised  by  means  of  a gorget;  cutting  on  both  edges,  and  which 
was  passed  into  the  vagina  at  first  horizontally,  so  as  to  nick  each  side  of 
the  vagina,  right  and  left,  then  obliquely  from  right  to  left,  and  from  above 
downwards,  and  lastly,  from  left  to  right  and  from  above  downwards,  thus 
making  six  incisions  with  a view  to  destroy  the  fibrous  and  condensed 
material  supposed  to  be  lying  outside  of  the  mucous  coat.  As  soon  as  this 
was  done,  an  application  was  made  of  caustic  potash,  which  was  immedi- 
ately neutralized  by  injections  of  vinegar  and  water.  The  pain  of  this  ope- 
ration was  very  great ; but  the  dilatation  was  quite  free.  The  lady  soon 


96 


CONGENITAL  NARROWNESS  OF  THE  VAGINA. 


recovered  from  the  pain  of  this  operation,  and  returned  to  her  own  state, 
with  a metallic  dilater  to  be  used  from  time  to  time,  with  a view  to  maintain 
the  degree  of  dilatation  thus  obtained.  I have  learned  that  the  success  was 
only  temporary,  and  that  the  narrowness  'has  returned,  so  that  she  has  had 
no  substantial  benefit  from  her  sacrifice. 

I have  long  been  well  satisfied,  that  in  the  dilating  of  strictures  of  the 
urethra,  a perfect  success  is  most  apt  to  follow  the  gentlest  mode  of  opera- 
tion: I have  also  familiarly  noticed  the  effects  of  the  pains  of  labour  on  the 
cervix  uteri,  as  well  as  on  the  vagina  and  perineum.  Now,  in  this  case,  when 
a contraction  of  the  womb  takes  place,  the  presenting  part  of  the  child  is 
impelled  against  the  resisting  cylinder  or  cone  of  the  cervix  uteri,  and  often 
without  causing  the  part  to  advance  at  all,  at  least  in  appearance  ; but  the 
strain  and  pressure  are  followed  by  a disposition  in  the  resisting  part  to  yield, 
so  that  at  the  next  pain  the  part  is  found  to  give  way  very  considerably,  and 
this  process  is  repeated  both  as  regards  the  cervix  and  the  vagina  and  peri- 
neum, and  it  is  by  acquiring  the  disposition  to  yield,  that  they  are  enabled 
to  yield  without  rupture  of  tissues.  A direct  application  of  the  force  not 
withdrawn,  as  by  the  intervals  of  labour  pains,  would  inevitably  rupture 
them.  I will  not  pretend  to  explain  the  physiological  cause  of  this  yielding 
temper,  acquired  even  by  non-muscular  structures  under  pressure,  but  I 
have  applied  the  fact  to  the  treatment  of  manual  operations  in  labour.  My 
hand  cannot  find  room  to  pass  into  the  vagina  in  a case  of  exploration  or 
turning,  until,  by  repeated  attempts  and  pressure,  the  parts  acquire  the  dis- 
position to  yield,  every  successive  pressure  finding  the  resistance  weakened. 
Ill  the  treatment  of  the  worst  forms  of  stricture  of  the  urethra,  inveterate  from 
fifteen  years  of  duration,  it  is  my  custom  merely  to  pass  a bougie  that  can 
be  moved  forwards  without  pain,  to  leave  it  in  situ  for  a few  moments,  and 
then  to  use  one  a little  larger  the  next  day,  and  so  on  in  succession  each 
day,  until  a full-sized  instrument  is  passed.  In  doing  so  I find  that  the 
antecedent  smaller,  has  given  the  disposition  to  yield  to  the  succeeding 
larger  bougie ; and  that  the  disposition  or  temper  of  the  tissues  so  acquired, 
is  not  lost  until  after  the  lapse  of  several  hours. 

It  has  already  been  stated  in  this  work,  by  M.  Colombat,  that  the  female 
urethra  itself  is  capable  of  very  great  dilatation,  even  equal  to  the  admission 
of  the  index  into  the  bladder.  The  rectum  can,  by  patient  trials,  be  made 
to  yield  sufficiently  to  admit  the  hand  into  its  cavity.  Under  such  views,  it 
appears  to  me  unnecessary,  in  any  case  of  narrowness,  to  resort  to  other 
than  simple  methods  of  graduated  dilatation.  I have  no  belief  that  the 
vagina  ought  to  be,  from  the  nature  of  its  physiological  office,  nor  that  it  is, 
in  point  of  fact,  composed  of  a fibrous  tissue  ; but  that  it  is  a mucous  tissue 
lying  in  the  midst  of  a condensed  mass  of  cellular  laminae  and  vessels  and 
nerves.  Under  these  impressions  1 should  not  deem  it  proper  to  use  cut- 
ting instruments  in  the  treatment  of  congenital  narrowness  or  accidental 
stricture  of  the  canal.  Early  in  the  year  1843,  a gentleman  from  a distance 


CONSTRICTED  VAGINA. 


97 


came  to  me  with  a letter  of  introduction,  and  communicated  the  information 
that  he  was  two  years  married,  but  had  been  hitherto  unable  to  consummate 
the  marriage  on  account  of  some  obstruction,  for  the  discovery  and  removal  of 
which  he  had  been  induced  to  come  to  this  city,  bringing  his  lady  with  him. 
I visited  her,  and  found  a very  healthy  and  fine  young  woman,  about  twenty- 
four  years  of  age.  She  had  menstruated  regularly,  and  enjoyed  in  all 
respects  good  health.  Her  menstruations  were  somewhat  painful  and 
tedious. 

Upon  separating  the  labia,  I was  for  some  time  at  a loss  to  discover  any 
appearance  of  a vagina.  The  clitoris  and  nymphae,  as  well  as  the  labia, 
were  perfectly  developed ; but  instead  of  the  os  magnum  there  was,  to  all 
appearance,  a complete  shallow  cul-de-sac.  It  was  not  until  I had  repeat- 
edly pressed  the  end  of  a probe  against  various  parts  of  the  extremity  of 
this  cul-de-sac,  that  I found  it  to  make  progress,  and  at  length  find  its  way 
along  the  course  of  a vagina,  which  appeared  to  be  filled  by  the  probe, 
so  strict  was  the  narrowness.  I next  introduced  a small  block-tin  bougie, 
and  then  a middle-sized  urethra  bougie,  which  was  closely  embraced 
by  the  vagina.  I succeeded,  on  this  first  occasion,  in  carrying  a full-sized 
urethra  bougie  to  the  bottom  of  the  vagina.  On  the  following  day  I used, 
without  difficulty,  a larger  bougie,  and  with  much  force  and  no  little  time, 
introduced  the  index  finger  as  far  as  the  os  uteri. 

I now  introduced  a half  hollow  cylinder  of  German  silver  to  the  bottom 
of  the  vagina,  and  then  concealing  the  apex  of  a similar  half  cylinder  in  the 
groove  of  the  first  one,  I carried  it  also  to  the  bottom  of  the  vagina.  One  was 
to  the  left,  the  other  on  the  right  side  of  the  vagina,  and  when  both  were 
adjusted,  they  equaled  in  size  the  index  finger,  which  I had  been  before 
able  to  introduce.  Fig.  12  is  a repre- 
sentation of  one  of  them,  and  Fig.  13 
resembles  it  viewed  in  profile.  I next 
pressed  into  this  speculum  or  dilater  the 
conical  bougie,  made  of  wood,  Fig.  14, 
and  very  slowly  carried  the  apex  forward, 
until  its  point  was  carried  home,  or  to 
the  extremity  of  the  half  cylinders.  The 
dilatation  gave  pain,  but  I did  not  think 
it  very  severe.  At  several  subsequent 
operations,  I separated  the  half  cylinders 
while  in  the  vagina  by  a larger  bougie 
than  the  one  before  mentioned,  which  I 
considered  large  enough,  and  then  fur- 
nishing her  with  a hollow  silver  gilt  bou- 
gie, about  one  inch  and  a quarter  in  diameter,  which  passed  without  the 
least  difficulty  to  the  bottom  of  the  vagina,  I sent  her  home  with  directions 
to  pass  the  bougie  once  a day. 

7 


98 


CONSTRICTION  OF  THE  VAGINA. 


Within  a few  days,  (May  20,  1844,)  I had  a letter  from  the  gentleman, 
requesting  me  to  send  him  another  silver  gilt  bougie  rather  larger  than  the 
last,  and  stating  that  he  believes  that  with  such  an  instrument  the  cure  will  be 
complete.  Here,  then,  is  a case  of  congenite  narrowness  of  the  entire  vagina 
in  a lady  two  years  married,  which  barely  admitted  a probe  for  thp  admis- 
sion of  which  the  orifice  was  with  difficulty  discovered,  and  which,  without 
great  pain,  or  the  least  evil  consequence,  was  cured  by  means  of  a simple 
apparatus  for  successive  dilatations.  I have  not  any  doubt  of  the  permanency 
of  the  cure,  for  I am  sure  that  the  congress  is  possible,  and  that  alone  will 
suffice  to  maintain  the  advantage  already  gained.  Should  the  lady  be  the 
subject  of  a future  pregnancy,  the  cure  will  be  beyond  the  possibility  of 
relapse.  I confess,  that  seeing  the  fine  health  enjoyed  by  the  lady  in  ques- 
tion, the  regularity  with  which  the  catamenial  office  is  performed,  and  the 
fitness  of  the  organs,  I am  in  hopes  of  learning  that  conception  has  taken 
place,  and  I should  entertain  no  fears  of  rupture  of  the  vagina,  under  the  dis- 
tension of  a labour  with  normal  presentations  of  a full-sized  foetus.  It  is, 
however,  a question  whether  the  imperfect  dilatation  of  a congenital  nar- 
rowness of  the  vagina  is  to  be  esteemed  a piece  of  good  fortune  for  the 
female  herself,  since  there  may  remain  an  insufficient  means  of  dilatation  for 
the  delivery  of  a child.  A case  that  fully  sets  forth  the  dangers  attending 
delivery  in  constricted  vagina,  is  related  in  the  Illinois  Med.  and  Surg. 
Journal  for  May,  1844.  It  is  stated  by  Daniel  Brainerd,  M.  D.,  a highly 
instructed  and  able  practitioner  and  teacher  at  Chicago.  Dr.  B.  was  called 
on  the  8th  April,  1844,  to  examine  the  body  of  a Mrs.  Donnahue,  who  had 
died  eight  hours  before  in  labour.  Labour  pains  began  on  the  2d  April, 
but  the  pains  went  off  entirely,  so  that  she  was  going  about  on  Thursday 
quite  well.  Labour  began  again  at  2 A.  M.  on  Friday,  and  continued  that 
day ; on  Saturday  the  patient  became  suddenly  ill,  with  cessation  of  the 
labour  pains,  and  the  signs  of  rupture  of  the  womb.  She  died  on  Monday, 
the  8th,  at  2 A.  M.  Dr.  B.  found  the  womb  ruptured  transversely  in  front, 
just  above  the  vagina,  and  the  child  and  placenta  lying  in  the  peritoneal 
sack,  which  prevented  the  usual  results  of  metro-peritonitis. 

Upon  Touching,  the  vagina  was  found  to  be  closed  above  the  middle  by 
adhesions  which  seemed  perfectly  to  have  obstructed  the  passage,  and  a 
firm  band  was  found  to  extend  from  the  left  side  of  it  upwards  and  back- 
wards, to  its  termination ; so  also  after  the  belly  had  been  opened,  drawing 
the  wound  upward,  “ a rent  was  perceived  at  its  anterior  part,  immediately 
above  the  attachment  of  the  vagina,  extending  from  side  to  side.  Passing 
the  finger  through  this  into  the  vagina,  it  was  arrested,  as  below,  by  the 
adhesions,  and  with  a finger  on  either  side,  the  septum  appeared  to  be  half 
an  inch  in  thickness,  and  of  very  firm  texture.”  “ The  closure  of  the 
vagina  appeared  to  be  perfect,  with  the  exception  of  a canal  through  which 
a quill  of  small  size  might  be  forced,  the  orifices  of  which  were  obscure. 


CONGENITE  STRICTURE  OF  THE  VAGINA. 


99 


The  septum  itself  was  very  dense,  and  composed  of  the  fibrous  tissue  of 
cicatrix.” 

It  appears  further,  from  Dr.  Brainerd’s  statement,  that  the  woman  was 
twenty-eight  years  of  age,  robust,  and  had  had  two  children,  the  first  still- 
born, after  a severe  labour,  the  second  still-born  at  the  seventh  month,  after 
a labour  of  four  hours,  having  suffered  very  little. 

It  appears  to  me,  from  the  perusal  of  the  case,  that  the  womb  was  lace- 
rated in  vain  attempts  to  overcome  the  resistance  of  this  stricture  of  the 
vagina,  and  as  the  woman  was*  seized  with  symptoms  of  labour  on  the 
2d  of  April,  there  was  time  between  that  and  the  6th,  when  the  organ  gave 
way,  to  have  dilated  the  vagina  by  the  bougie  and  the  instrument  I have 
described,  or  even  by  sponge  tent  diligently  employed.  I have  preferred 
to  state  this  important  case  in  brief  here,  in  order  to  raise  the  question  as  to 
the  safety  of  exposing  a female,  by  an  imperfect  dilatation  of  a congenite 
narrowness  of  the  vagina,  to  the  dangers  consequent  on  conception ; and 
also  to  show  that  in  this  instance  fecundation  took  place,  though  the  aperture 
barely  admitted  a quill  of  small  size. — M.] 

Congenite  narrowness  of  the  vagina  does  not  always  prevent  con- 
ception, which  may  be  effected,  in  some  instances,  without  the  intro- 
mission of  the  penis.  The  cases  already  cited  at  page  76,  and  others 
in  the  records  of  medicine,  are  too  numerous  to  leave  the  least  doubt 
upon  this  point.  “ There  may  be  found,”  says  Boyer,  in  the  Me- 
mories de  VAcademie  des  Sciences , 1774,  “a  case  of  narrowness 
of  the  vagina,  which  disappeared  during  pregnancy  without  any 
artificial  aid.  A married  woman,  sixteen  years  of  age,  had  so  nar- 
row, a vagina  that  a common  quill  could  not  be  passed  into  it.  It 
was  not  closed  by  any  membrane.  At  the  menstrual  period  she  felt 
a pain  in  the  region  of  the  womb,  which,  without  doubt,  was  due  to 
the  difficulty  of  discharging  the  menstrual  excretion  through  the 
vagina,  which  was  narrower  near  the  uterine  than  the  vulvar  ex- 
tremity. Independently  of  the  sufferings  she  experienced  from  her 
menstruations,  she  was  troubled  with  a young  and  vigorous  husband, 
who  hoped  to  force  a passage,  but  in  vain.  At  length,  after  eleven 
years,  she  conceived,  while  not  the  least  change  had  been  effected  in 
the  state  of  the  canal.  Her  surgeon  was  satisfied  that  she  could  not 
be  delivered  per  vias  naturales.  Nevertheless,  at  the  fifth  month  the 
vagina  began  to  dilate,  and  continued  to  do  so,  and  at  length  acquired 
the  ordinary  dimensions  of  the  healthy  vagina,  and  she  was  happily 
brought  to  bed.”  The  same  collection,  174S,  contains  an  analo- 
gous case.  A lady,  at  Brest,  had  the  vagina  so  narrow  that  it  would 
scarcely  admit  of  the  introduction  of  a quill.  Notwithstanding,  she 
became  pregnant,  and  in  three  hours  of  labour,  gave  birth  to  a large 
healthy  child.  In  this  case  the  dilatation  took  place  only  on  the 
night  of  the  labour. 

The  Lancette  Francaise , Gazette  des  Hopitaux , for  August  14, 
1832,  contains  an  extract  from  the  Brazilian  Medical  Review , 
relating  the  following  case.  A mulatto  woman  was  violated  by  a 


100  ACCIDENTAL  OBLITERATION,  ETC.  OP  VAGINA. 

Brazilian.  Her  mistress,  who  did  not  notice  the  enlargement  of  the 
girl’s  abdomen,  and  who  supposed  the  servant  to  be  affected  with 
dropsy,  administered  a variety  of  medicines  supposed  to  be  of  a 
deobstruent  character.  In  the  course  of  a few  months  the  pregnancy 
was  evident,  and  a surgeon,  who  was  called  upon  to  attend  the  case, 
found  the  vagina  so  narrow  as  scarcely  to  admit  the  introduction  of 
a writing,  quill.  She  was  safely  delivered. 

We  shall  conclude  our  remarks  upon  narrowness  of  the  vagina  by 
one  additional  case.  Mad.  C.***,  twenty-eight  years  of  age,  who 
had  been  teu  years  married,  but  without  being  able  to  admit  of  the 
consummation  of  her  marriage,  having  applied  to  Dr.  Caron  du  Vil- 
lards,  that  gentleman  ascertained  that  she  had  a congenite  narrow- 
ness of  the  vagina,  so  great  as  to  permit,  with  difficulty,  the  introduc- 
tion of  a common  catheter  ; and  he  recommended  the  dilatation  by 
means  of  gum  elastic  bougies,  gradually  increasing  the  size  of  the 
instruments  to  be  used.  After  a perceptible  increase  of  size  of  the 
canal  had  been  in  this  way  obtained,  he  substituted  for  the  bougies, 
a sort  of  chaplet  of  sponge  tent,  the  discs  of  which  were  cut  out  by  a 
punch.  The  discs  of  sponge  tent  were  strung  upon  a proper  thread, 
and  strongly  pressed  together  so  as  to  compose  a single  cylinder, 
capable  of  being  admitted  into  the  vagina  as  readily  as  a bougie  of 
similar  size.  After  some  weeks’  continuance  of  the  use  of  this  pow- 
erful dilater,  the  vagina  had  become  so  ample  that  Madame  C.*** 
became  pregnant,  and  was  safely  delivered  under  the  care  of  M. 
Hatin,  adjunct  Professor  of  the  Faculty  of  Paris.  M.  Caron  du  Vil- 
lards  informed  us  of  a similar  successful  treatment,  in  the  case  of 
Madame  Taforeau,  thirty-four  years  of  age,  and  who  had  been  mar- 
ried since  her  fourteenth  year,  and  who  now  is  Portiere  at  No.  13 
Rue  de  la  Seine.  The  only  difference  in  the  two  cases  is  that  the 
latter  person  has  not  become  pregnant,  as  Mad.  C.***  did,  who,  it 
must  be  remarked,  was  a younger  woman. 

In  some  cases  the  vagina  is  so  narrow  that  the  canal  seems  to  be 
quite  lost. 

OF  ACCIDENTAL  OBLITERATION  AND  STRICTURE  OF  THE  VAGINA. 

By  obliteration  of  the  vagina,  we  understand  either  an  accidental 
adhesion  of  its  parietes,  whether  more  or  less  complete,  or  a stricture 
of  the  canal  affecting  its  whole  extent,  or  only  a part  of  it. 

The  causes  of  vaginal  obliteration  are  always  accidental : when  it 
is  incomplete  and  constitutes  only  a stricture,  the  diagnosis  of  the 
case  may  very  certainly  be  made  either  by  the  introduction  of 
a probe,  or  by  ascertaining  that  the  menses  have  a proper  issue. 
When  the  obliteration  is  complete,  the  walls  of  the  vagina  are  more 
or  less  adherent  over  an  extent  that  varies  in  the  different  samples ; 
but  so  that  there  exists  no  communication  whatever  between  the 
womb  and  the  vulva. 

Adhesion  and  stricture  of  the  vagina  may  be  situated  at  the  lower 
end,  at  the  centre,  or  at  the  upper  extremity  of  the  tube.  These  two 
sorts  of  obliteration  that  commonly  are  the  results  of  violent  inflam- 


ATRESIA  OF  THE  VAGINA. 


101 


mation,  or  any  of  the  causes  that  we  before  pointed  out,  while  on  the 
subject  of  imperforation,  may  likewise  be  occasioned  by  the  thicken- 
ing and  induration  of  the  vaginal  tissue,  which  sometimes  follow  the 
imprudent  use  of  astringent  injections,  employed  to  remove  the  traces 
of  libertinism.  The  spontaneous  swelling  of  the  mucous  glands,  of 
the  rugae  and  the  adipose  cells  of  the  vagina,  is  also  to  be  regarded 
as  among  the  causes  of  obliteration  of  the  tube,  more  or  less  complete. 

Dr.  S6galas,  in  1825,  communicated  to  the  Acad.de  Med.  the  case 
of  a woman  whose  vagina  having  been  obliterated  in  consequence 
of  a laborious  labour,  caused  a complete  retention  of  the  menses  to 
take  place.  At  the  sitting  of  March  22,  1834,  there  was  communi- 
cated to  the  Academy  the  case  of  another  woman,  whose  vagina 
was  obliterated  in  consequence  of  the  injection  into  it  of  half  a glass- 
ful of  sulphuric  acid,  which  she  did  herself,  with  the  wicked  inten- 
tion of  bringing  on  abortion.  As  the  upper  two-thirds  of  the  canal 
were  obliterated,  the  womb  gave  way  by  laceration,  and  the  unhappy 
creature  died  undelivered. 

[It  is  surprising  to  reflect  on  the  rapidity  with  which  occlusion  of  the 
vagina  may  take  place  after  parturition,  and  that  without  any  perceptible 
cause  or  sign  being  evident,  by  which  it  may  be  known  that  the  process  of 
obliteration  is  going  on. 

About  two  years  ago,  a young  woman  at  Salem,  New  Jersey,  gave  birth 
to  a healthy  child  after  a moderate  labour.  She  had  no  illness  during  the 
lying-in,  and  was  in  all  respects  as  well  as  women  usually  are.  At  the  end 
of  the  month  she  rode  to  the  distance  of  twenty  miles  from  home,  to  the 
funeral  of  a relative,  and  returned  the  next  day.  It  was  now  ascertained 
that  there  was  no  passage  beyond  the  bottom  of  the  vulva,  and  she  was 
brought  to  this  city  that  I might  take  charge  of  the  case.  Upon  separating 
the  labia  very  widely,  I found  a puckered  seam  at  the  bottom  of  the  vulva; 
but  I could  nowhere  make  a probe  pass  into  the  vagina,  so  that  the  atresia 
was  complete.  The  anterior  wall  had  cohered  with  the  posterior  wall  of 
the  canal.  She  came  here  when  her  child  was  about  two  months  old,  so 
that  the  cohesion  was  not  yet  so  firm  as  to  indicate  the  use  of  the  scalpel, 
for  the  purpose  of  effecting  its  disruption. 

According  to  my  own  experience,  the  cohesion  of  the  labia  in  young 
children,  may  be  easily  overcome  by  pressing  upon  the  seam  with  the  bulb 
of  a probe,  and  I have  always  readily  succeeded  by  operating  in  that  mode. 
In  the  case  of  this  woman  I adopted  the  same  plan,  and  keeping  the  genital 
orifice  strongly  stretched  with  the  thumb  and  medius,  I made  horizontal 
touches  with  the  bulb  of  a probe  at  the  points  of  union,  and  without  losing 
more  than  two  or  three  drachms  of  blood,  succeeded  in  breaking  up  the 
cohesion  of  the  opposing  mucous  walls,  the  villi,  which  seemed  to  be  mutu- 
ally implanted  in  the  adverse  surfaces,  drawing  out  in  the  distraction  of  the 
labia  and  the  touches  of  the  probe,*  precisely  as  happens  in  the  breaking  up 
of  cohesions  of  the  labia.  I soon  made  an  aperture,  through  which  I readily 
passed  the  index  finger  to  the  os  uteri.  I recommended  to  her  physician 


102 


CASE  OF  ATRESIA  OF  VAGINA. 


the  continued  use  of  cereoles,  to  be  prepared  extempore  and  used  daily, 
until  the  full  amplitude  of  the  organ  should  be  restored.  The  cohesion 
occupied  more  than  a quarter  inch  of  the  calibre  of  the  vagina. 

In  the  following  case  the  vagina  was  lost,  and  is  cited  from  th ePhilad. 
Pract.  of  Mid.,  by  the  translator  of  this  work,  p.  383,  2d  edit. 

“A  woman,  from  a distant  part  of  the  country,  came  to  the  city  last 
spring,  (1837,)  to  consult  Dr.  J.  Randolph,  who  was  good  enough  to  invite  me 
to  see  the  patient  with  him.  Her  story  was  as  follows.  More  than  two 
years  have  elapsed  since  she  gave  birth  to  a healthy  child,  the  labour  being 
so  exceedingly  rapid  that  the  infant  was  born  before  the  physician  could 
reach  the  house.  The  after-birth  did  not  come  away  for  an  hour,  during 
which  time  there  was  flooding.  The  woman  became  very  weak.  In  a few 
days  she  was  attacked  with  inflammation  of  the  vagina,  accompanied  with 
enormous  discharges  of  matter  and  great  thick  pieces  of  flesh , to  use  her 
own  account.  She  was  never  examined  by  her  physician,  who,  however, 
directed  washes,  injections,  &.c.  After  a long  and  exhausting  hectic,  attended 
with  extreme  emaciation,  her  discharges  grew  less  copious,  and  she  gradu- 
ally, and  at  the  end  of  some  months  got  well.  There  was,  however,  no 
vagina ; not  even  a cul-de-sac ; there  was  only  the  genital  fissure  left.  Of 
course  no  catamenia  could  appear  ; but  after  several  months  of  good  health, 
she  began  to  complain  of  pain  or  misery  in  the  hypogastric  and  pelvic 
regions.  The  pains  recurred  with  intervals  of  a month,  and  having  at  length 
become  intolerable,  she  found  her  health  declining,  and  came,  as  before  said, 
to  consult  that  able  and  eminent  surgeon,  Dr.  Jacob  Randolph. 

“There  was  a tumour  in  the  hypogastrium  that  reached  half  way  up  to 
the  navel;  it  was  of  a firm  and  resisting  feel,  not  unlike  a contracted  womb 
soon  after  delivery.  As  there  was  no  vagina,  the  finger  was  passed  into  the 
rectum,  where  it  came  in  contact  with  the  same  tumour,  which  seemed 
to  occupy  the  excavation  as  it  is  occupied  by  the  child’s  head  in  labour, 
filling  up  the  cavity  entirely.  Upon  separating  the  labia  there  was  nothing 
but  the  genital  fissure:  there  was  no  way  for  a probe  to  pass  upwards.  A 
sound  was  passed  into  the  bladder  and  retained  there  until  a finger  was  also 
introduced  into  the  rectum.  The  only  texture  that  separated  the  sound 
and  the  finger  seemed  to  be,  upon  careful  examination,  the  walls  of  the 
urethra,  and  the  coat  of  the  bowel ; there  was  no  vagina  to  be  felt.  Hence 
Dr.  Randolph  and  I agreed  in  the  opinion  that  the  vagina  had  been  wholly 
destroyed  by  the  sloughing  process  which  took  place  shortly  after  her  con- 
finement. We  entertained  no  doubt  as  to  the  nature  of  the  tumour  which 
occupied  the  pelvis  and  lower  part  of  the  abdomen  ; it  was  the  womb  her- 
metically sealed,  and  retaining  within  its  cavity  the  accumulated  menstrua- 
tions of  nearly  two  entire  years. 

“After  much  diligent  search,  we  were  unable  to  discover  the  cervix  or  os 
uteri;  but  we  supposed  they  might  possibly  be  turned  upwards  towards 
the  top  of  the  os  pubis,  so  as  to  elude  any  investigation  made  through  the 


CASE  OF  ATRESIA  OF  VAGINA. 


103 


rectum  alone,  the  only  possible  way  of  making  researches  in  the  case.  No 
vestige  of  a vagina  was  discoverable  by  the  taxis  ; nevertheless,  supposing  it 
possible  that  the  whole  of  the  tube  might  not  have  been  destroyed,  and  that 
haply  its  upper  extremity  might  be  reached  by  the  bistoury,  Dr.  Randolph 
operated  with  a view  to  make  an  artificial  vagina,  and  to  discover  the  re- 
mainder, if  any,  of  the  original  one. 

“ Introducing  a strong  metallic  staff,  slightly  curved,  into  the  bladder,  he 
took  his  seat  in  front  of  the  patient,  who  laid  upon  her  back  on  the  bed 
with  the  knees  drawn  up  and  separated.  I held  the  staff  firm,  while,  with 
the  left  index  in  the  rectum,  to  serve  as  a guide,  he  dissected  by  horizontal 
strokes  of  the  bistoury,  the  tissue  betwixt  the  rectum  and  urethra,  and  carried 
his  incision  very  nearly  up  to  the  substance  of  the  womb  itself,  without 
having  wounded  either  the  rectum  or  the  urethra:  when  he  had  completed 
his  incisions,  the  finger  could  be  carried  up  to  the  bottom  of  the  cul-de-sac 
he  had  formed  by  so  skilful  and  accurate  a use  of  the  bistoury. 

“ In  consequence  of  our  uncertainty  relative  to  the  situation  of  the  os 
uteri,  and  from  his  having  successfully  removed  so  considerable  a portion  of 
the  barrier  that  opposed  the  escape  of  the  contents  of  the  uterus,  Dr.  Ran- 
dolph suspended  his  operation  at  this  point  with  the  following  views. 

“ It  was  resolved  to  keep  the  passage  open  by  the  use  of  a bougie,  made 
as  light  as  possible  and  of  a sufficient  size.  The  bougie  was  made  of  silver, 
gilt,  about  four  inches  in  length,  and  about  as  large  as  the  thumb,  its  weight 
not  more  than  two  drachms,  being  hollow.  We  hoped  that  by  using  this 
bougie  a few  months,  the  progress  of  the  case  would  be  such  as  to  bring  the 
os  uteri  to  the  extremity  of  the  instrument,  by  means  of  the  increasing  ex- 
pansion of  the  uterine  globe,  and  that  the  contents  of  the  womb  would  dis- 
charge themselves  into  the  artificial  vagina,  or  that  they  might  be  so  dis- 
charged by  a future  incision.  The  lady  returned  to  her  own  country,  and 
after  an  absence  of  three  months,  came  back  to  the  city,  still  suffering  under 
the  same  misery , with  increased  magnitude  of  the  uterus,  but  without 
having  had  any  discharge  from  the  vagina.  She  had  constantly  worn  the 
bougie.  Upon  examination,  we  found  the  vagina  was  now  covered  with  a 
smooth  surface  resembling  mucous  membrane  ; the  upper  end  of  the  bougie, 
when  withdrawn,  was  covered  with  a sort  of  muco-purulent  matter,  tinged 
with  blood.  The  sufferings  of  the  patient  from  the  distension  of  the  womb 
were  very  great,  and  it  was  on  that  account  resolved  to  puncture  the  organ 
in  order  to  draw  off  its  contents.  On  the  8th  July,  1837,  Dr.  Randolph 
and  Dr.  R,.  M.  Huston,  who  had  been  invited  by  us  to  witness  the  operation, 
met  me  at  the  lodgings  of  the  patient. 

“The  tumour,  felt  through  the  vagina,  was  hard  and  resisting,  like  an 
enlarged  ovarium ; it  was  softer,  and  its  walls  thinner  when  examined 
through  the  rectum.  At  Dr.  Randolph’s  request  I made  use  of  a curved 
trocar  enclosed  within  its  canula.  The  trocar  was  about  five  inches  in 
length,  and  about  the  size  of  a small  writing  quill.  The  patient  was  laid 


104 


CASE  OF  ATRESIA  OF  VAGINA. 


upon  her  back  near  the  edge  of  the  bed.  I introduced  the  forefinger  of  the 
left  hand  into  the  rectum,  and  having  directed  the  end  of  the  finger  to  a point 
upon  the  tumour  that  felt  most  yielding,  carried  the  point  of  the  trocar  along 
that  finger  to  the  place  in  question,  and  giving  to  the  point  of  the  instrument 
a direction  as  nearly  as  possible  perpendicular  to  the  surface  of  the  tumour, 
pushed  it  through  the  resisting  tissues  until  I found  it  had  freely  entered  the 
cavity  of  the  womb;  the  trocar  was  now  withdrawn,  leaving  the  canula 
in  its  place.  There  immediately  issued  from  the  open  end  of  the  canula  a 
dark  red  viscous  substance,  without  odour,  of  the  consistence  of  meconium, 
and  as  adhesive  as  that  substance.  The  puncture  was  scarcely  felt  by  the 
patient.  In  the  course  of  twenty-four  hours,  during  which  the  canula  was 
permitted  to  remain  in  situ  properly  secured,  about  twenty-five  ounces  of 
this  fluid  were  discharged;  the  uterine  tumour  had  disappeared  from  the 
hypogastrium,  and  the  mass,  as  felt  through  the  rectum,  was  greatly  reduced 
in  size,  and  far  more  movable.  As  all  the  liquid  seemed  now  to  be  evacu- 
ated, the  canula  was  withdrawn;  no  discharge  followed  its  withdrawal.  The 
patient  had  no  symptoms  attributable  to  the  puncture  ; she  rapidly  recovered 
her  strength,  and  left  the  city  with  renovated  health,  and  nearly  free  from 
the  misery  that  had  so  long  embittered  her  existence.  In  the  course  of 
about  a month  after  she  returned  to  her  home,  she  had  a very  copious  dis- 
charge from  the  vagina,  of  a fluid  similar  in  consistence  to  that  which  came 
away  through  the  canula,  but  of  a whitish  colour,  after  which  her  health 
greatly  improved. 

“ On  the  14th  Dec.,  1837,  while  on  her  way  to  this  city,  for  the  purpose 
of  taking  further  advice,  she  discharged  about  twenty-five  ounces  of  a sub- 
stance in  all  respects  similar  to  that  which  was  first  extracted. 

“ In  the  course  of  the  summer  of  1843, 1 again  saw  this  lady.  Her  health 
was  good  ; she  has  tolerably  regular  menstruation,  which  gives  pain.  The 
artificial  vagina  has  disappeared,  leaving  a sinuous  opening,  very  small, 
which  communicates  with  the  cavity  of  the  womb,  and  by  which  she  men- 
struates. She  could  not  be  prevailed  upon  to  submit  to  any  further  treat- 
ment. I think  it  highly  probable  that  the  sinus  could  be  readily  dilated 
into  a full-sized  vagina.” — M.] 

Notwithstanding  that  in  some  of  the  cases  the  adhesions  can  be 
easily  and  without  much  effort  broken  up,  yet  in  other  circumstances, 
the  purulent  matter  becomes  thickened  to  such  a degree  as  to  form, 
with  the  vaginal  surfaces,  a sort  of  solid  concretion,  capable  of 
resisting  the  greatest  violence,  especially  if  the  cohesions  are  of  long 
standing. 

[I  cannot  avoid  remarking  the  singular  use  of  the  word  purulent  in  the 
above  passage.  I presume  it  is  to  be  understood  as  referring  not  to  pus,  as 
such,  but  to  the  coagulating  or  organizable  lymph,  which  is  the  bond  of 
union  in  such  cases. — M.] 

Where  the  inflammation  has  been  very  violent,  the  ruga*  of  the 


TREATMENT  OF  STRICTURE  OF  VAGINA. 


105 


vagina  become  so  confounded  with  each  other,  that  it  becomes  nearly 
impossible  to  dissect  them  up  without  perforating  one  of  the  sides 
of  the  canal,  and  wounding  either  the  bladder  or  the  rectum;  the 
degree  of  the  inflammation,  then,  may  serve  as  the  index  of  indica- 
tion, as  to  whether  an  operation  should  be  attempted  or  rejected,  for 
it  is  as  dangerous  as  it  is  difficult,  where  the  obliteration  exists  for 
the  whole  extent  of  the  tube.  In  such  cases,  Morgagni  proscribes  it 
entirely,  and  Blasius,  as  well  as  Benevoli,  each  of  whom  had  the 
temerity  to  dissect  the  vaginal  parietes  after  they  had  been  coalesced 
from  inflammation,  was  obliged  to  leave  the  operation  unfinished. 
We  shall,  however,  bring  forward  a case  in  which  a successful  result 
was  obtained  by  Professor  Flamand,  and  which  we  take  from  the 
account  given  by  Dr.  Villette  of  Paris,  in  1821.  A country  woman 
was  delivered  by  a midwife,  who  ruptured  the  vagina.  The  menses 
did  not  return  after  this  confinement ; the  husband  was  discontented 
with  his  wife,  supposing  that  his  embarrassment  was  owing  to  her 
want  of  condescension.  Being  at  last  quite  out  of  patience  with  her 
condition,  she  went  to  Strasbourg  to  M.  Flamand’s  clinic,  in  order  to 
undergo  an  operation.  There  was  found  a very  small  opening,  that 
with  difficulty  admitted  the  introduction  of  a grooved  director,  but 
what  was  the  surprise  of  the  learned  professor  to  discover  that  four 
inches  of  the  vaginal  tube  had  cohered  ! In  spite  of  the  difficulty  of 
the  case  he  succeeded  in  removing  the  deformity,  for  she  had  a child 
a year  afterwards. 

Where  the  obliteration  is  not  complete,  we  may  succeed  in  arrest- 
ing its  progress,  at  first  by  antiphlogistic  measures,  and  by  promoting 
the  dilatation  of  the  vaginal  parietes  by  baths,  fumigations  and  emol- 
lient injections ; and  by  the  use  of  vaginal  suppositories  of  beurre  de 
cacao , and  the  use  of  the  dilating  measures  heretofore  pointed  out, 
while  speaking  of  congenital  narrowness  of  the  canal. 

Among  the  fittest  means  for  the  fulfilment  of  this  last-named  indi- 
cation, there  is  one  we  have  made  use  of  with  great  advantage,  and 
which  is  recommendable  as  being  both  easy  of  performance  and  not 
at  all  painful. 

It  consists  in  introducing  within  the  vagina  a cylindrical  sac,  very 
thin  and  soft,  and  which  is  made  of  the  caecal  appendage  of  a calf  or 
a sheep,  and  which  was  introduced  by  an  English  physician  named 
Condon,  for  the  purpose  of  guarding  the  penis  against  infection  in 
impure  coitus.  In  using  this  sac,  there  should  be  attached  to  it  a 
gum-elastic  sound,  so  that  after  the  sac  has  been  cautiously  intro- 
duced into  the  vagina,  it  may  be  filled  with  air,  at  first  in  moderate 
quantity,  and  then  in  quantity  progressively  increased  from  day  to 
day.  The  sac  should  at  first  be  a small  one  ; the  succeeding  ones  to 
be  larger  and  larger,  and  often  changed  to  prevent  their  putrefaction 
within  the  passage.  The  air  may  be  prevented  from  escaping  by  a 
small  cork  fixed  to  the  outer  end  of  the  gum-elastic  sound,  or  by 
adjusting  upon  it  a small  brass  cock,  which  would  conveniently 
allow  the  air  to  escape  a little  if  the  sac  should  happen  to  be  painful 
from  too  great  an  inflation.  The  use  of  this  method  should  be  con- 
tinued until  the  vagina  recovers  its  natural  dimensions. 


106 


OBTURATION  AND  ITS  TREATMENT. 


In  the  entire  obliteration  of  the  vagina,  there  remains  no  other 
remedy  than  a dangerous  and  difficult  operation  which  we  shall 
describe  under  the  head  of  obturation  of  that  canal. 


OF  OBTURATION  OF  THE  VAGINA  AND  THE  MEANS  OF  CURE. 

In  pathology  the  word  obturation  refers  to  the  accidental  deve- 
lopment of  any  substance,  filling  up  more  or  less  completely  a 
natural  cavity. 

Obturation  of  the  vagina,  which  indicates  either  the  presence  of  a 
foreign  body  in  the  tube,  or  an  intermediate  substance  confounded 
with  its  walls,  has  excited  but  little  attention  among  medical  men 
because  it  has  been  rarely  presented  to  their  observation. 

A vaginal  obturation  may  be  complete  or  incomplete,  congenite  or 
accidental.  The  causes  of  accidental  obturation  must  be  regarded  as 
symptoms  of  other  pathological  lesions,  and  not  as  organic  affections. 
Such  are  the  polypous, fungous  or  syphilitic  excrescences,  membranous 
bands  and  fleshy  columns  developed  in  the  vagina,  the  swelling  and 
mutual  approximation  of  the  carunculae,*  encysted  and  steatomatous 
tumours,  vaginal  hernia,  and,  indeed,  all  sorts  of  tumours  and  vege- 
tations that  may  take  their  rise  upon  the  mucous  membrane  of  the 
vagina,  or  which,  though  foreign  to  it,  may  nevertheless  project  into 
or  against  its  calibre. 

An  obturation  may  even  be  produced  by  prolapsus  of  the  womb, 
the  cervix  of  which  may  contract  adhesions  to  the  internal  edge  of 
the  labia  externa.  A case  of  the  kind  is  recorded  in  the  Diet,  des 
Sci.-Med .,  (article  Vagina,)  less  as  a case  of  obturation  than  because 
the  os  uteri  being  partially  open,  so  as  to  admit  the  finger,  any  want 
of  attention  might  lead  to  the  mistaking  of  the  orifice  for  that  of 
stricture  of  the  vagina. 

When  the  obturation  is  congenital,  it  may,  like  the  accidental  case, 
be  complete  or  incomplete,  and  occupy  a greater  or  less  extent  of  the 
vagina.  That  canal  is,  therefore,  susceptible  of  becoming  primarily 
obstructed,  not  only  at  any  given  point  of  its  surface,  but  even 
throughout  its  whole  extent,  which  is,  in  such  a case,  converted  into 
a solid  cylinder,  very  thick  and  composed  of  a cellulo-fibrous  mate- 
rial, quite  analogous  to  the  substance  of  the  vaginal  parietes. 

Like  the  vaginal  imperforation,  the  obturation  of  the  tube  is,  for 
the  most  part,  undiscovered  until  the  age  of  puberty,  or  until  symp- 
toms relative  to  amenorrhoea  lead  to  its  detection.  However,  the 

* Riolanus,  who  was  appointed  Professeur  Royal  d’Anatomie  by  Louis  XIII.,  and 
afterwards  became  physician  to  Queen  Mary  de  Medicis,  has  published  (Anat.seuAu- 
ihrup.  cap.  2.  p.  35,)  the  case  of  a woman  in  whom  the  carunculae  myrtiformes  were 
so  closely  approximated,  that  it  was  hardly  possible  to  introduce  a probe  into  the 
opening  betwixt  them.  Notwithstanding  this  almost  complete  obturation,  the  patient 
was  happily  delivered  of  a child,  after  the  excision  of  the  tumour  had  been  per- 
formed. There  is  also,  in  the  xxiv.  vol.  of  the  Did.  des  Sci.  Med.,  p.  133,  a case  in 
which  the  shreds  of  the  hymen,  after  defloration,  had  united  again  so  as  to  form  a 
complete  diaphragm  in  the  lower  part  of  the  vagina.  The  myrlil'orm  caruncles  have 
been  sometimes  mistaken  for  syphilitic  excrescences;  to  mention  is  sufficient  to 
avoid  such  an  error.  Our  readers  should  reflect  that  the  fleshy  lumps  resulting  from 
the  destruction  of  the  hymen  are  generally  smooth,  loose  and  of  a rose  tint. 


CASES  OF  OBTURATION. 


107 


symptoms  accompanying  obturation  are  in  general  less  severe  than 
those  of  the  other  case,  because  it  has  been  found  to  coincide  almost 
always  with  an  imperfect  development  of  the  womb  itself,  which 
militates  in  favour  of  the  principle  set  forth  by  M.  Andral,*  that  a 
part  is  generally  not  found  to  be  wanting  or  imperfectly  formed, 
unless  those  that  precede  it  in  the  natural  state  have  themselves 
undergone  an  arrest  of  development. 

Although  obturation  of  the  vagina,  when  complete,  or  even  incom- 
plete, renders  the  sexual  union  impossible,  the  partial  introduction  of 
the  penis  may  be  effected  if  the  obstacle  is  found  only  at  the  upper 
end  of  the  canal.  A woman  so  constituted  would  be  exposed  to  great 
danger  by  too  violent  an  effort  in  coitu.  The  vagina  might  be  rup- 
tured, as  in  the  case  mentioned  by  Plazzani  in  the  following  words. 
CiJuvenis  quid  am , cum  sponsa  jnvenciila  prima  node  congressurns , 
valida  veretri  intrusione  et  violent  a festinatione  non  modo  uteri 
cervicem , sed  et  ipsum  intestinum  rectum  pern/pit ( De  Par  lib. 
Generate  lib.  ii.  cap.  14.  p.  164.) 

As  the  records  of  medicine  possess  but  few  authentic  cases  of  vagi- 
nal obturation,  we  shall  report  some  cases  by  Dehaen,  Morgagni, 
Lieutaud,  Foder6,  Cormick,  Professor  Stoltz,  and  mentioned  also  in 
a thesis  by  Dr.  Waille  de  St.  Lupicien,  as  now  to  be  related. 

Dehaent  speaks  of  a girl  twenty-four  years  of  age,  who,  dying  in 
consequence  of  retention  of  the  menses  three  days  after  an  unsuccess- 
ful operation,  in  which  the  instrument  penetrated  the  urethra  and  to 
the  neck  of  the  bladder,  was  found  to  have  part  of  the  vagina  con- 
verted into  a solid  fleshy  body  an  inch  in  diameter,  beyond  which 
the  passage  was  filled  with  a dark-coloured  sanies,  and  was  of  capa- 
city sufficient  to  contain  the  head  of  a foetus. 

Morgagni, f while  making  the  autopsy  of  a female  seventy  years 
of  age,  who  died  with  peripneumony,  after  having  been  long  sub- 
ject to  an  asthmatic  disorder,  found  the  vagina  completely  obstructed 
except  at  each  extremity,  by  a sort  of  solid  cjdinder  composed  of  a 
substance  uniformly  white  and  pretty  hard,  so  that  it  was  not  possi- 
ble to  discriminate  betwixt  it  and  the  parts  surrounding  it  and  con- 
tinuous with  it.  The  vagina  did  not  appear  to  have  lost  any  part  of 
its  diameter.  The  walls  of  the  uterus  were  thick,  the  orifice  small, 
the  inner  surface  somewhat  moist,  and  the  lower  part  of  the  cervix 
contracted. 

A woman  named  La  Hure,§  of  the  Faubourg  du  Temple,  at 
Paris,  having  never  been  indisposed,  notwithstanding  the  absence  of 
the  catamenia,  and  having  been  six  years  a wife  without  the  con- 
summation of  the  marriage,  was  examined  and  unsuccessfully  operated 
on,  August  6th,  1734,  by  Dejours,  the  surgeon,  and  was  subsequently 
examined  by  Levret,  and  afterwards  by  Saumet,  Ferrin,  Petit  and 

* Anat.  Pathol.,  t.  i.  p.  109. 

f Ratio.  Medend.,  t.  iii.  pars.  6.  cap.  2;  Lieutaud,  Histoire  Nat.  Medicale,  t.  i.  p. 
326  ; Diet,  des  Sci.  Med.,  article  Imperforation ; Duges  Mai.  de  l’Uterus,  t.  i.  p.  271. 

i Lettre  67  and  10. 

§ Causes  celebres,  t.  vil.  and  10.  20.  cause ; Fodere,  Med.  Leg.,  2d  edit.  t.  i.  p.  385 ; 
Diet,  des  Sci.  Med.,  article  Marriage. 


108 


STOLTZ’S  CASE. 


Morand.  She  died  at  Lyons  ten  years  after  this,  and  upon  the 
autopsy  it  was  discovered  that  the  womb  and  the  vagina  constituted 
merely  a compact  solid  substance,  without  any  cavity. 

Dr.  Cormick*  was  called  to  examine  a woman  twenty-three  years 
of  age,  who,  from  the  age  of  sixteen,  had  felt  once  a month  the 
symptoms  arising  from  retention  of  the  menses ; and  was  a victim 
of  the  most  intolerable  pains.  Upon  exploring  the  genital  parts  he 
found  a fleshy  resisting  mass,  that  appeared  to  fill  up  the  whole 
vagina.  He  was  obliged  to  plunge  a trocar  to  the  depth  of  four 
inches,  before  he  passed  through  the  obstacle  that  prevented  the 
escape  of  the  menses. 

To  these  four  cases  we  shall  add  a case  from  the  practice  of  Mr. 
Stoltz.  It  appears  to  us  to  be  the  more  interesting,  as  differing,  from 
the  others  in  the  total  absence  of  bad  symptoms,  and  as  presenting  a 
specimen  of  perfect  obturation,  with  distinct  parietes,  and  in  the  faci- 
lity and  the  happy  success  of  the  operation  undertaken  for  the  cure. 

Madame  N.,  of  Stotzheim,  had  reached  her  twenty-third  year 
without  having  menstruated.  The  only  menstrual  efforts  she  had 
experienced  consisted  in  attacks  of  epistaxis,  which,  at  the  age  of 
puberty  had  recurred,  but  without  any  character  of  periodicity;  and 
from  time  to  time,  every  week  or  every  fortnight,  pains  in  the  hypo- 
gaster,  but  not  affecting  the  region  of  the  sacrum  at  all.  Having 
been  married  in  the  year  1827,  it  was  impossible  to  consummate  the 
union,  and  it  was  not  until  four  years  had  elapsed,  that  is,  in  1831, 
after  she  had  been  four  years  married,  that  she  submitted  to  an 
examination  by  a midwife,  who  found  the  orifice  of  the  vagina 
closed. 

M.  Stoltz,  being  requested  to  see  the  lady,  Sept.  25,  1831,  for  the 
purpose  of  performing  the  operation,  found  her  of  middling  stature, 
the  countenance  perfectly  feminine,  the  mammae  pretty  well  deve- 
loped, the  skin  fair  and  soft,  the  mons  well  covered  with  hair,  the 
external  genitalia  of  a natural  appearance,  and,  learned  in  a word, 
that  she  had  all  the  attributes  of  the  sex,  except  that  the  orifice  of  the 
vagina  was  closed  by  a thick  membrane,  salient  some  eight  or  ten  lines 
like  the  end  of  the  finger  of  a glove,  and  which  admitted  of  being 
pushed  back  to  an  equal  distance  into  the  canal  of  the  vagina,  like 
the  finger  of  a glove  turned  inside  out.  This  projecting  part  was 
somewhat  wrinkled,  of  a rose  colour,  and  perfectly  indolent. 

At  first,  M.  Stoltz  was  of  opinion  that  it  would  only  be  necessary, 
by  means  of  scissors,  to  cut  off  the  principal  part  of  this  membrane, 
in  order  to  open  a free  passage  into  the  vagina.  But  he  found  that 
the  excision  only  gave  access  to  the  interior  of  a small  sac  filled  with 
white  mucus,  of  a milky  character,  and  found  that  the  vagina  was 
completely  obstructed  and  filled  with  a cellulo-fibrous  material,  which 
he  partly  dissected  with  the  scissors,  introduced  as  far  as  he  could 
properly  use  them,  and  then  with  the  index  and  medius  fingers  intro- 
duced into  the  passage ; after  which  he  broke  up  the  bands  or  bridles 
that  remained  with  a Flamant’s  guarded  bistoury.  In  order  not  to 

* Med.  and  Philos.  Commentaries,  vol.  ii.  p.  188;  Voigtel  Handbuch  der  Pathol. 
, Anat.,  p.  438. 


STOLTZ’S  CASE 


109 


lose  the  direction  of  the  vagina,  he  placed  a sound  in  the  urethra, 
which  enabled  him.  to  distinguish  both  the  urethra  and  the  bas-fond 
of  the  bladder. 

After  having  thus  torn  up  the  cellular  bands  that  obstructed 
nearly  the  entire  length  of  the  vagina,  with  his  fingers,  partly  by 
separating  them  in  various  directions,  and  partly  by  using  them 
as  blunt  crotchets,  he  at  length  reached  a small  hard  tubercle, 
divided  by  a transverse  slit  into  two  parts.  This  was  the  vaginal 
portion  of  the  cervix  uteri.  He  succeeded,  with  great  difficulty,  in 
breaking  up  the  bands  that  concealed  it  like  a thick  spider’s  web.  By 
means  of  the  fingers  in  the  vagina  and  the  sound  in  the  bladder,  and 
also  by  depressing  the  hypogastric  integuments  sufficiently  to  meet 
the  fingers  in  the  vagina,  he  satisfied  himself  that  the  tubercle  was 
nothing  more  nor  less  than  the  womb  itself  in  a rudimental  state,  and 
from  five  to  six  lines  in  length  from  top  to  bottom.  A careless  ope- 
rator, or  one  not  thoroughly  acquainted  with  the  anatomy  of  the 
parts,  might  very  readily  have  broken  through  one  of  the  culs-de-sac 
of  the  vagina,  while  endeavouring  to  find  the  womb  itself. 

After  the  completion  of  the  operation,  the  vagina  was  found  to  be 
sufficiently  capacious  to  admit  of  the  consummation.  The  constrictor 
muscle  was  found  to  be  perfect  by  its  contraction  on  the  index.  A 
stout  pledget  of  lint  with  a tape  fastened  to  its  base,  and  spread 
with  cerate,  was  introduced  into  the  vagina,  and  directions  were 
given  to  the  midwife  to  change  it  twice  a day. 

The  operation  was  not  very  painful,  the  patient  made  no  outcries, 
and  she  did  not  lose  more  than  half  an  ounce  of  blood. 

Fifteen  days  afterwards  the  midwife  informed  M.  Stoltz  that  the 
lady  had  discovered  a slight  discharge  of  a few  drops  of  blood  from 
the  vagina,  which  was  at  first  attributed  to  an  imperfect  menstrua- 
tion ; but  as  it  did  not  return,  it  was  thought  that  it  might  have  pro- 
ceeded from  a congress,  with  some  laceration. 

Two  years  and  a half  had  elapsed  when  M.  Stoltz  received  the 
last  accounts  of  the  state  of  his  patient.  She  was  in  the  same  condi- 
tion, had  never  menstruated,  felt  from  time  to  time,  and  at  nearly 
equal  intervals,  the  symptoms  of  the  catamenial  action,  and  had  no 
difficulty  in  the  cohabitation. 

Inasmuch  as  the  symptoms  of  a case  of  obturation  might  be  con- 
founded with  those  of  imperforation  or  obliteration,  and  of  absence  of 
the  vagina,  we  shall  now  call  to  mind  some  striking  traits  that  may 
suffice  to  remove  all  uncertainty  on  this  point. 

Where  the  imperforation  is  incomplete,  menstruation  may  take 
place  ; if  it  be  complete,  the  finger,  if  introduced  within  the  vulva, 
encounters  a membrane  forming  a fluctuating  tumour,  with  an  oval 
projection  more  or  less  prominent  in  front,  and  in  such  a case,  a 
simple  incision  dispels  every  doubt  and  dissipates  every  symptom. 
Where  the  occlusion  is  owing  to  incomplete  obliteration,  the  dis- 
charge of  the  menses  takes  place,  and  a style  may  be  passed  into  the 
contracted  vagina : if  the  obliteration  is  complete,  and  affects  the 
whole  breadth  of  the  canal  to  a greater  or  less  extent  of  its  longi- 
tude, the  diagnosis  of  the  case,  which  is  always  accidental , may  be 


110 


OPINIONS  ON  OPERATION 


made  out  by  examining  by  the  rectum,  and  with  a sound  introduced 
into  the  bladder.  The  obstacle  that  results  from  obliteration , instead 
of  being  as  in  obturation  a compact,  thick  cylindrical  body,  filling  up 
the  vagina,  consists  in  a pretty  thin  membranous  septum*,  or  in  cohe- 
sion of  the  sides  of  the  canal, — a cohesion  that  may  affect  the  whole 
length  or  only  certain  points  of  it.  Moreover,  in  the  case  of  obtura- 
tion, if  the  finger  be  introduced  into  the  vulva,  it  will  be  arrested  by 
a very  resisting  body,  whereas  in  imperforation  and  obliteration,  the 
obstacle  is  always  movable,  membranous  and  fluctuating. 

Nearly  all  the  authors  who  have  spoken  of  occlusion  of  the  vagina 
have  furnished  few  details  on  the  subject ; and  have  confounded  the 
accidental  agglutination  of  its  parietes  with  obturation  of  the  canal 
produced  by  the  intermediate  body,  whose  principal  characters  we 
have  now  pointed  out.  This  is  probably  the  reason  why  they  desig- 
nate these  new  kinds  of  occlusion  by  the  same  term  obliteration,  and 
that  they  denounce  the  operation  as  impracticable  and  very  danger- 
ous in  all  instances,  wherein  the  obstacle  extends  to  some  depth  into 
the  vagina. 

Naboth,*  who  participated  in  the  generally  admitted  opinions,  and 
who  also  confounded  the  accidental  cohesion  of  the  vaginal  walls 
with  the  congenital  obturation  in  question,  said  that  when  there 
existed  an  intermediate  fleshy  body,  the  operation  ought  to  be  re- 
nounced, for  there  would  be  reason  to  apprehend  either  a dangerous 
haemorrhage  or  very  serious  inflammation  as  the  consequence  of  -its 
performance.  Morgagni,!  who  entertained  the  same  notions,  advised 
his  women  rather  to  submit  to  divorce  than  suffer  an  incision  to  be 
rashly  made.  Heisterf  also  refused  to  operate  for  two  females  who 
came  to  consult  him  ; lastly,  Plenck,§  Mahon, ||  Fodere,1T  and  nearly 
all  the  writers  on  medical  jurisprudence  look  upon  this  sort  of  atresia 
as  cause  of  absolute  impotence  and  beyond  the  reach  of  art. 

Notwithstanding  the  well  or  ill  founded  and  generally  exaggerated 
fears  of  the  writers  on  this  subject,  we  are  of  opinion  that  circum- 
stances may  exist  to  indicate  the  propriety  of  an  operation ; but 
that  the  greatest  prudence  is  required  on  the  occasion ; care  being 
taken  not  to  wound  the  bladder  or  rectum.  Even  if  it  be  true  that 
the  results  have,  in  a major  part  of  the  instances,  been  unfortunate, 
it  may  with  propriety  be  attributed  to  the  method  having  been  ill 
chosen,  or  the  case  having  been  contra-indicated,  as  ordinarily  hap- 
pens when  in  consequence  of  a complete  obliteration,  the  walls  of 
the  vagina  have  become  agglutinated  throughout  their  entire  extent. 

Previously  to  making  any  attempt  at  operation  it  would  be  the 
dictate  of  prudence,  always  to  wait  until  compelled,  as  it  were,  by 
the  occurrence  of  symptoms  of  retained  menses,  or  of  other  symptoms 
threatening  the  very  life  of  the  patient ; and  which  thus  afford  proof, 
not  only  of  the  existence  of  a womb,  but  of  its  not  communicating 
with  any  other  cavity — which,  were  it  the  case,  would  render  the 
•operation  useless. 

* Disput.  de  Sterilit.  Mulierum,  p.  23.  f Lettre,  No.  46. 

i Institut.  Chirurg.  t.  ii,  p.  403  and  405.  § Element.  Med.  Chir.  Forensis,  p.  3. 

U Medicine  L6gale,  t.  i,p.  63.  ^ Med.  Legale,  2d  edit.  p.  384. 


FOR  OBTURATION  OF  VAGINA. 


Ill 


SURGICAL  TREATMENT  OF  ACCIDENTAL  COHESION  OF  THE  VAGINAL 

PARIETES ; AND  OF  CONGENITAL  OBTURATION  OF  THE  VAGINA. 

In  a case  where  the  necessity  for  action  is  clearly  established,  the 
patient  should  be  prepared  for  it  in  the  same  manner  as  if  about  to 
undergo  one  of  the  greater  operations  of  surgery;  but  if  upon  a 
retention  of  the  menses,  symptoms  should  arise  deemed  sufficiently 
important  to  menace  her  safety,  no  delay  should  be  allowed.  In 
such  an  instance  the  only  preparation  would  consist  in  evacuating 
the  rectum  and  bladder,  with  the  view  of  rendering  them  less  liable 
to  be  wounded  by  the  bistoury. 

Whether  the  design  be  to  dissect  asunder  the  vaginal  walls  acci- 
dentally coherent,  or  whether  we  be  about  to  treat  a case  of  conge- 
nital obturation  produced  by  an  intermediate  membrane,  the  patient 
should  be  placed  as  for  the  operation  of  lithotomy  ; then  having  in- 
troduced the  index  finger  of  the  left  hand  into  the  rectum  and  a sound 
into  the  bladder,  for  the  purpose  of  exploring  the  parts  anew — and 
to  give  a surer  direction  to  the  knife,  the  incision  should  be  made 
little  by  little  with  a straight  bistoury,  or,  with  what  we  should  pre- 
fer, a convex  scalpel — and  thus  the  walls  of  the  vagina  should  be 
separated,  proceeding  with  all  the  prudence  and  care  demanded  by 
so  serious  an  operation. — (See  Fig.  15.) 


Fig.  15. 


That  we  may  be  able  throughout  the  whole  course  of  the  operation 
to  retain  one  finger  within  the  rectum,  and  at  the  same  time  be  ac- 
quainted with  the  situation  of  the  adjacent  parts  without  being  com- 
pelled to  make  use  of  the  left  hand,  we  have  invented  an  instrument 
which  is  adjusted  upon  the  end  of  the  right  index  finger,  like  a 
thimble,  and  which  is  terminated  by  a Fig.  16. 

small  cutting  edge,  convex  in  shape,  and 
about  three  lines  in  length.  (Fig.  16.) 

By  using  this,  we  can,  with  the  medius 
of  the  right  hand,  continually  inquire  as 
to  the  resistance  of  the  tissues  after  each 
little  incision,  and  guide  the  cutting  edge 
constantly  until  it  reaches  the  sanguine  collection,  that  has  called 
for  the  performance  of  the  operation.  After  which  we  should  pro- 
ceed as  directed  under  the  head  of  vaginal  imperforalion. 

If  we  are  acting,  not  to  remedy  a case  of  obliteration,  but  a con- 
genite  obturation,  the  operation  that  offers  the  greatest  prospect  of 
success,  in  this  latter  case,  and  that  because  there  is  always  an  inter- 
mediate substance,  and  consequently  a greater  space  betwixt  the 
rectum  and  the  urethra,  ought  to  be  performed  as  follows,  and  with 
the  preliminaries  already  mentioned. 

In  the  first  place,  if  there  should  be  found  a 'membrane  projected 


112 


OPERATIONS  FOR  OBTURATION. 


outwards  at  the  vulva,  and  placed  in  front  of  the  obstacle,  it  should 
be  removed  by  the  scissors  or  with  a straight  bistoury,  cutting  from 
before  backwards  ; or,  what  is  still  better,  by  means  of  two  incisions, 
united  below,  like  the  letter  V,  so  as  more  certainly  to  avoid  the  risk 
of  injuring  the  urethra. 

After  having  performed  this  little  preliminary  operation,  whicli 
will  have  exposed  the  real  nature  of  the  obstacle,  the  surgeon  will 
plunge  a long  narrow  bistoury  into  the  middle  of  the  space  comprised 
betwixt  the  anus  and  the  meatus  urinarius,  then  withdrawing  the 
bistoury,  he  should  introduce  the  index  of  the  left  hand  into  the 
wound,  in  order  to  dilate  the  opening  thus  made,  and  then  continue 
to  push  the  bistoury  forwards,  guarding  and  directing  its  progress  by 
means  of  the  finger  kept  near  its  point. ' 

Should  it  be  preferred,  the  surgeon  may  make  use  of  a trocar, 
which,  being  introduced  gently  and  carefully,  admits  of  a more  rapid 
operation,  which,  however,  is  less  certain  than  the  other.  For  the 
purpose  of  guarding  against  injury  to  the  bladder,  a grooved  director 
may  be  introduced  into  the  wound  made  by  the  trocar,  and  adjusted 
so  as  to  allow  the  point  of  a bistoury  moving  in  the  groove,  to  make 
two  oblique  incisions  that  coincide  in  the  direction  of  the  urethra, 
like  an  inverted  ^ . 

Whatever  may  be  the  method  adopted,  it  is  indispensable,  for  the 
certainty  of  the  operation,  to  keep  the  index  of  the  left  hand  in 
the  rectum,  and  to  let  an  assistant  take  charge  of  the  sound  that  is 
in  the  bladder,  directing  him,  agreeably  to  Velpeau’s  advice,*  to 
press  the  point  of  it  towards  the  hypogastrium.  Throughout  the 
whole  course  of  the  operation,  the  urethra  must  be  raised  up  by 
means  of  the  sound,  so  as  to  keep  it  as  much  as  possible  out  of  the 
way  of  the  cutting  instruments. 

Should  the  obstructing  substance  be  found  to  be  yielding,  the  con- 
duct of  M.  Stoltz  might  be  imitated,  who  succeeded  in  restoring  the 
vagina,  and  broke  up  all  the  bands  of  cellular  matter,  by  the  alter- 
nate use  of  his  fingers,  the  scissors,  and  the  guarded  bistoury  of 
Flamand.  Should  a considerable  haemorrhage  come  on,  we  might 
follow  the  example  of  Dr.  Voisin,t  in  a case  of  obliteration,  and 
divide  the  operation  into  two  stages ; and  it  might  be  concluded  after 
a short  delay,  during  which  the  wound  should  be  filled  with  a piece 
of  sponge  tent.  After  the  destruction  of  the  obstacle,  union  of  the 
parts  is  to  be  prevented  in  the  manner  pointed  out  under  the  head 
of  imperforation  of  the  vagina. 

The  accidents  accompanying  this  operation  that  are  most  to  be 
feared  are  haemorrhage  and  inflammation.  The  former,  when  not 
excessive,  prevents  the  occurrence  of  the  latter,  which  has  never  been 
met  with  except  in  cases  of  imperforation  or  obliteration.  Inasmuch 
as  in  both  these  kinds  of  occlusion,  the  assistance  of  art  is  not 
required  until  after  the  appearance  of  important  symptoms,  the  in- 
flammation may  be  supposed  to  depend  less  upon  the  operation  itself 
than  on  the  suddemchange  effected  in  the  volume  of  the  womb,  and 

f Theses  de  Paris,  1806,  p.  116. 


Elern.  de  Med.  Opera!.,  t.  iii.  p.  576. 


OCCLUSION  OF  THE  CERVIX. 


113 


the  tension  of  the  vagina  and  its  appendages.  In  every  case  let  the 
patient  be  subjected  to  the  most  rigorous  regimen,  and  to  an  antiphlo- 
gistic treatment,  conformable  to  the  violence  of  the  fever  and  in- 
flammation. 

Whatsoever  may  be  the  nature  and  extent  of  the  obstacle  compos- 
ing the  obturation,  the  attempt  to  remedy  the  difficulty  ought  not  to 
be  deferred  when  the  life  of  the  patient  is  compromised.  The  opera- 
tion is,  doubtless,  the  only  plank  of  safety  ; but  the  principles  of  our 
art,  as  well  as  humanity  itself,  command  us  to  avail  ourselves  of  it, 
although  liable  to  be  cast  upon  a shoal,  that  by  means  of  it  we  may 
avoid  another  and  the  fulfilment  of  the  ancient  adage,  so  well  ex- 
pressed by  Virgil,  in  the  line  — 

“Incidit  in  Scyllam,  qui  vult  vitare,  Charybdin.” 

Notwithstanding  the  proscription  of  this  operation  by  such  authors 
as  Naboth,  Morgagni,  and  Heister,  and  by  many  of  the  modern  sur- 
geons, it  is  sufficiently  justified,  even  admitting  its  dangerous  nature, 
by  the  successes  of  Messrs.  Desgranges,  Delpech,  Cabaret,  Ventusa, 
Flamand,  Willaume,  Toulmouche  de  Rennes,  Stoltz,  and  other  names 
that  it  is  unnecessary  to  cite  in  this  place. 

OCCLUSION  OF  THE  CERVIX  UTERI. 

In  some  instances  while  the  vagina  itself  is  perfectly  free  from 
obstruction,  it  is  the  canal  of  the  neck  of  the  womb  that  is  the  seat 
of  congenite  obturation,  or  of  a complete  or  incomplete  obliteration. 

This  deformity,  which  was  first  described  by  Akakia,  may  depend 
upon  various  accidental  causes.  Thus  the  sequelae  of  a labour,  the 
introduction  of  a foreign  body,  lacerations  from  mechanical  causes, 
the  amputation  of  the  cervix  uteri,  ulcers,  burns,  tumours,  polypi, 
&c.,  &c. ; these,  and  all  the  other  causes  that  we  have  enumerated  in 
our  article  on  vulvar  and  vaginal  atresia,  may  serve  to  explain  the 
formation  of  occlusion  of  the  cervix,  and  the  retention  of  the  menses 
consequent  thereto. 

Morgagni , while  dissecting  the  sexual  organs  of  a female,  found 
the  mouth  of  the  womb  closed  up  by  a white  thick  membrane  that 
shut  off  all  communication  betwixt  the  cavity  of  the  uterus  and  the 
vagina.  Armand , Simson  and  Frank ,*  Messrs.  Cabrol,\  Gau- 
thier,\ Willaume, § Hervez  de  Chegoin, ||  Delpech, *\\  Desgranges  ** 
and  some  other  writers,  have  likewise  noticed  either  obturation 
or  obliteration,  more  or  less  complete,  of  the  vaginal  orifice  of  the 
womb. 

The  consequences  of  uterine  atresia  are  perhaps  still  more  danger- 
ous than  those  of  the  other  kinds  of  imperforation  of  which  we  have 
already  spoken.  This  arises  from  the  circumstance  that  in  this  case 
we  are  more  easily  led  into  the  mistake  of  regarding  it  as  a state  of 
pregnancy,  and  as  the  symptoms  have  a closer  resemblance  to  those 

* De  Retentionibus,  t.  ii.  p.  39.  f Ann.  Litt.  Med.  etrang.,  t.  ii.  p.  484. 

* Nouveau  Journal  de  Med.,  t.  vii.  p.  30.  § Seance  de  l’Acad.  de  Med., 23  Mai,  1826. 

H Idem  24  Novembre,  1829.  ^ Memorial  du  Prof.  Delpech,  Mar.  1830. 

**  Idem  No.  du  mois  d’Avril,  1830. 

8 


114 


OCCLUSION  OF  THE  CERVIX. 


of  gestation,  it  is  more  difficult  to  make  the  diagnosis  of  retained 
menses. 

The  occlusion  may  exist  in  the  interior  of  the  cervix,  or  at  its  ori- 
fice ; and  there  seems  to  be,  according  to  Boyer,  a continuation  of 
the  inner  membrane  of  the  vagina.  Some  practitioners,  however, 
among  whom  may  be  mentioned  Latour,  Morland,  Flamand  and 
Martin,  are  of  opinion  that  an  obturation  can  possibly  take  place 
during  pregnancy. 

An  examination  by  Touching,  or  the  inspection  of  the  parts,  ena- 
bles us  pretty  clearly  to  distinguish  the  faulty  conformations  of  the 
cervix,  whether  primitive  or  accidental,  and  even  to  observe  the 
fluctuation  occasioned  by  the  accumulation  of  blood  in  the  viscus. 

Benevoli , surgeon  in  chief  to  the  Hospital  of  Florence , who  has 
candidly  made  known  both  his  success  and  his  errors,  was  consulted 
on  account  of  a girl  affected  with  suppression  of  urine,  accompanied 
with  the  usual  phenomena.  Having  tried,  without  success,  to  intro- 
duce a sound  into  the  urethra,  he  discovered  that  he  could  not  make 
it  reach  as  far  as  the  bladder,  because  the  distension  of  the  womb 
had  elongated  the  urethra.  An  angle  in  the  canal  of  the  urethra  had 
been  formed  by  the  distended  womb,  which  had  thrust  the  bladder 
itself  forwards  and  above  the  ossa  pubis,  so  that  the  orifice  of  the 
bladder  no  longer  corresponded  with  that  of  the  urethra. 

Benevoli,  as  he  could  not  succeed  in  relieving  the  bladder  on  the 
first  day,  put  off  an  attempt  to  pass  the  catheter  until  the  next  day. 
Instead  of  introducing  the  sound  into  the  urethra,  he  passed  it  into 
the  vagina  without  being  aware  of  the  mistake  he  had  made.  The 
instrument,  which  was  directed  towards  the  mouth  of  the  womb,  not 
being  able  to  penetrate  into  the  cavity  of  the  organ,  Benevoli,  sup- 
posing that  it  was  the  sphincter  vesicae  under  powerful  contraction, 
and,  that  he  might  be  able  to  overcome  it  by  force,  pushed  the  sound 
onwards,  and  it  plunged  into  the  womb.  Immediately  after  this,  there 
escaped  a very  large  quantity  of  a brownish  liquid,  resembling  wine 
lees,  which  was  at  first  mistaken  for  bloody  urine.  But  after  the 
menstrual  collection  had  come  away,  the  urine  was  rapidly  discharged 
from ’the  urethra,  a circumstance  which  showed  him  that  he  had  in- 
troduced his  sound  into  the  uterus  and  not  into  the  urethra.  The 
patient,  who  for  three  years  had  found  her  abdomen  increasing  in 
size  every  month,  instantly  obtained  great  relief,  with  the  immediate 
disappearance  of  the  enormous  abdominal  swelling  caused  by  the 
accumulation  of  menstrual  blood  in  the  uterine  cavity.  Benevoli 
estimated  the  quantity  discharged  after  the  performance  of  the  opera- 
tion at  thirty-two  pounds. 

If,  in  any  case,  the  symptoms  we  have  described  should  be  sup- 
posed to  depend  on  a primitive  or  accidental  faulty  conformation,  the 
sexual  parts  ought  to  be  examined  with  the  most  scrupulous  care,  in 
order  to  learn  whether  the  absence  of  the  womb  does  not  furnish  an 
insurmountable  bar  to  the  object  proposed  to  be  attained. 

In  order  to  remedy  the  occlusion  of  the  neck  of  the  womb,  an 
attempt  should  be  made  to  pass  up  an  ordinary  sound,  with  a view 
to  overcome  the  obstacle,  if  possible.  If  that  cannot  be  done,  then 


ATRESIA  OF  THE  FALLOPIAN  TUBES. 


115 


the  resistance  should  be  overcome  by  means  of  a puncture,  either 
with  a bistoury,  wrapped  with  linen  to  within  a few  lines  of  its 
point,  [or,  what  is  better,  wrapped  in  a ribbon  of  adhesive  plaster 
spread  on  fine  linen — M.,]  or  with  a trocar,  the  canula  of  which,  as 
advised  by  Hervez  de  Chegoin,  ought  to  be  left  in  the  wound,  as  a 
conductor  to  a piece  of  gum  elastic  catheter,  to  be  followed  after- 
wards by  a female  catheter. 

Whatsoever  may  be  the  instrument,  or  the  method  employed  in 
the  operation,  the  inflammatory  consequences  require  the  same  atten- 
tions that  we  have  recommended  in  speaking  of  the  operations  for 
atresia  of  the  vulva  and  vagina.  To  prevent  or  combat  these  dread- 
ful consequences,  let  it  be  remembered  that  they  demand  the  most 
energetic  methods  ; among  which  are  bleeding,  long-continued  warm 
bathing,  as  of  the  first  rank;  the  woman  should,  so  to  speak,  be 
made  to  live  in  the  bath  until  the  cure  is  complete. 

ATRESIA  OF  THE  FALLOPIAN  TUBES. 

The  Fallopian  Tubes  are  two  musculo-vascular  conduits,  floating 
loose  in  the  abdomen,  and  extending  from  the  superior  angles  of  the 
womb  to  the  margins  of  the  superior  strait  of  the  pelvis.  As  these 
tubes,  which  are  supposed  capable  of  the  state  of  erection,  are  hid- 
den from  our  researches  in  the  living  subject,  it  is  not  possible 
to  ascertain  the  existence  of  an  imperforation  of  them  except  in  an 
autopsy. 

Atresia  of  the  tubes,  like  the  other  imperforations  of  the  genitalia, 
is  divided  into  congenite  or  accidental , and  complete  or  incomplete 
atresia. 

The  causes  of  congenital  atresia  are  unknown ; in  some  instances 
both  the  tubes  may  be  affected,  and  the  causes  may  be  accidental ; 
thus,  the  formation  of  a membrane  that  happens  to  be  developed 
near  the  point  where  the  tubes  communicate  with  the  cavity  of  the 
womb,  in  consequence  of  an  attack  of  inflammation ; a preceding 
wound  ; an  operation — as  the  Caesarian  operation,  for  example  ; a 
blow  on  the  hypogastrium,  suffice  to  disclose  the  nature  of  the  acci- 
dental deformity  in  question. 

The  most  common  kind  of  atresia  is  that  that  takes  place  near  the 
insertion  into  the  womb ; it  is  also,  sometimes,  observed  near  the 
ovaries,  to  which  they  are  found,  in  some  samples,  intimately  united. 

Both  the  total  obturation  and  obliteration  being  beyond  the  re- 
sources of  the  art,  and  being  not  ascertainable  until  after  death,  we 
here  close  our  observations  upon  the  subject,  being  satisfied  with 
merely  mentioning  the  fact  of  their  existence. 


116 


ABSENCE  OF  THE  VAGINA,  ETC. 


OF  ABSENCE  OF  THE  VAGINA— AND  OF  CASES  IN  WHICH  THE  VAGINA 
OPENS  INTO  THE  RECTUM  OR  BLADDER. 

Both  Morgagni*  and  Dupuytrent  met  with  women  in  whom  the 
vagina  was  only  of  one-third  its  usual  diameter  and  length.  Engel  % 
and  Boyer§  found  the  vagina  wholly  wanting,  and  the  urethra  and 
bladder  in  immediate  contact  with  the  rectum.  Individuals  affected 
with  these  anomalous  forms  may,  at  the  same  time,  be  wholly  un- 
provided with  the  uterus, ||  or,  if  it  does  exist,  it  may  be  small,  ill 
formed,  and  unfit  for  the  office  of  menstruation.  Yet,  even  under 
such  circumstances,  the  womb  has  been  found  quite  natural  as  to  its 
conformation,  but  it  often,  in  that  case,  communicates  externally  by 
an  unusual  aperture,  and  opens  by  a sort  of  unnatural  vagina  into 
the  bladder, IT  or  into  the  urethra,**  oi;  the  rectum, tt  or  even  opens 
on  the  anterior  surface  of  the  abdomen.ff 

These  unnatural  openings  of  the  vagina,  which  are  of  exceedingly 
rare  occurrence,  almost  always  coincide  with  an  obturation  of  the 
anterior  part  of  the  canal. 

As  these  deformities  do  not  compromise  the  existence  nor  even  the 
health  of  the  subjects  of  them,  they  remain  unknown  until  the  age  of 
puberty  ; that  is  to  say,  until  the  menstrual  fluid,  escaping  per  anum, 
or  by  the  meatus  urinarius  makes  manifest  the  unnatural  disposition 
of  the  parts. 

If,  in  the  case  of  a total  absence  of  the  uterus,  the  mucous  mem- 
brane of  the  bladder  becomes  the  seat  of  a sanguine  evacuation, 
vicarious  of  the  menses,  it  would  not  be  easy  to  ascertain  that  the 
blood  is  furnished  by  the  bladder  and  not  by  the  womb  itself,  whose 
absence  it  would  be  then  a difficult  matter  to  pronounce  upon.  In- 
asmuch, however,  as  all  these  anomalous  conditions  are  beyond  the 
reach  of  the  resources  of  the  art,  we  shall  close  our  observations  upon 
them  at  this  point. 

[I  subjoin  an  interesting  letter,  that  I have  received  from  Professor  Mat- 
ter, and  which  needs  no  comment. 

October  4,  1844. 

“In  compliance  with  your  request,  I send  a brief  notice  of  the  case  of 
“ Imperforate  Anus,”  of  which  you  spoke  the  other  day.  About  the  last 
of  April,  1844,  I was  requested  by  Dr.  Jewell  to  visit,  in  consultation, 
the  female  infant  (two  weeks  old)  of  one  of  his  patients.  On  examina- 
tion, the  following  condition  of  things  was  discovered : — The  rectum  ter- 

* De  Sedibus  et  Causis  Morb.,  epist.  46. 

-j-  Repert.  Anat.  Pathol.,  t.  v.  p.  90. 

t De  Utero  Defic.  apud  Schlegel,  t.  i.  p.  259.  Mem.  of  Berlin,  1774.  Jour,  des 
Savants,  1777. 

§ Traite  des  Mai.  Chirurg.,  t.  x.  p.  422. 

H Morgag.  loc.  cit.  epist.,  11\  12.  Dupuytren,  Joe.  cit.  Boyer,  loc.  cit.  p.  423.  t.  x. 
Caillot,  Mem.  de  la  Soc.  Med.  d’Emulation,  t.  ii.  470. 

1 Boyer,  loc.  cit.  p.  408. 

**  Madame  Boivin  and  M.  Duges,  Traitb  des  Mai.  de  l’Uterus,  t.  i.  p.  273. 

f j-  Barbaut  Cours  d’Accouch.,  p.  59.  Orfila,  Med.  Legale,  t.  i.  p.  150. 

tt  Morgagni,  loc.  cit.  epist.  67.  p.  7.  Dr.  VVaille  cites  from  Huxmann,  (Opusc. 
Phys.  Medic,  t.  iii.  p.  3,)  the  case  of  a female,  23  years  of  age,  whose  meatus  urina- 


ABSENCE  OF  THE  VAGINA,  ETC. 


117 


minated  in  a cul-de-sac,  which  extended  to  within  three  or  four  lines  of 
the  natural  position  of  the  orifice  of  the  gut,  which  spot  was  occupied  by 
dense  cellular  tissue  and  common  integument,  and  no  trace  of  the  anal 
opening  could  be  distinguished.  We  were  told  that  the  child  was  in  the 
habit  of  passing  its  feces  through  the  vagina,  and  that  each  evacuation  was 
attended  with  violent  efforts',  while  the  fecal  matter  was  moulded  into  small 
threads.  Separating  the  labia,  an  opening  about  the  size  of  a small  duck- 
shot  was  discovered  just  within  the  fourchette,  and  above  it,  a well-formed 
hymen.  Through  this  opening,  a probe  was  readily  passed  into  the  rectum, 
and  also  through  the  hymen  into  the  vagina,  and  both  canals  appeared  per- 
fectly normal,  with  the  exception,  of  course,  of  the  defect  already  ascribed. 
The  indication  was  obvious,  and  I at  once  proposed  the  following  operation: 
With  the  view  of  establishing  a proper  channel  for  the  feces,  and,  at  the 
same  time,  dispose  the  orifice  between  the  rectum  and  vagina  to  contract 
and  thus  heal.  Passing  a small  grooved  director  from  the  vagina  into  the 
rectum,  I forced  out  the  tissues  forming  its  lower  extremity,  and  then  thrust 
a trocar  down  to  the  director  and  directly  through  the  spot  usually  occupied 
by  the  natural  orifice  of  the  intestine.  Withdrawing  both  instruments,  I 
next,  with  a probe-pointed  bistoury,  enlarged  the  opening  made  by  the 
trocar,  and,  as  soon  as  this  was  accomplished,  the  child  passed  an  immense 
quantity  of  fecal  matter,  apparently  with  much  relief.  A sponge-tent  was 
then  introduced  into  the  rectum,  and  the  nurse  instructed  as  to  its  objects 
and  use. 

“Being  on  the  eve  of  sailing  for  Europe,  I did  not  see  the  child  again, 
but  suggested  the  continued  use  of  the  sponge-tent,  until  the  opening  made 
had  lost  all  disposition  to  contraction  ; and,  after  this,  if  the  orifice  in  the 
vagina  did  not  heal  of  its  own  accord,  in  consequence  of  the  natural  channel 
for  the  feces  being  established,  that  it  should  be  touched  occasionally  with 
the  argent,  nitrat. 

“ I did  not  deem  this  a case  in  which  the  operation  of  Amussat  was  advisa- 
ble, nor  was  it  one  that  indicated  excision  of  the  tissues  occupying  the 
position  of  the  anal  orifice,  nor  could  any  operation  upon  the  fistulous  open- 
ing between  the  rectum  and  vagina  be  with  propriety  proposed.  I preferred 
the  trocar  to  a sharp-pointed  bistoury , for  performing  the  operation,  for  the 
simple  reason  that  wounds  made  with  the  former  instrument  are  much  less 
prone  to  heal  by  the  first  intention  than  when  the  latter  is  employed  ; and 

rius  opened  upon  the  middle  of  the  abdomen,  a little  below  the  navel,  by  two  distinct 
orifices,  from  which  the  urine  was  constantly  escaping  guttatim.  A littlfi  lower 
down  the  orifice  of  the  vagina  was  seen.  Still  lower  down  was  seen  a transverse 
orifice,  scarcely  admitting  the  introduction  of  the  little  finger,  which  was  separated 
from  the  vagina  by  a thick  membrane,  and  communicating  with  the  rectum,  whose 
termination  was  quite  natural  as  to  its  situation.  This  woman,  whose  menses  were 
perfectly  regular,  had  married  a robust  sailor,  by  whom  she  had  a child.  The  surgeon, 
Bonnet,  who  had  charge  of  her  in  the  labour,  was  unable  to  deliver  her  until  he  had 
made  an  incision  into  the  membrane  that  separated  the  vagina  from  the  abnormal 
anus.  Both  the  child  and  its  mother  were  saved. 


118 


ABSENCE  OF  THE  WOMB. 


as  it  was  one  object  of  course  to  prevent  the  close  of  the  gut  again,  an  event 
by  no  means  uncommon,  when  a simple  conical  incision  is  made  with  a bis- 
toury, I adopted  the  plan  of  operating  described.  I have  not  seen  the  child 
since  my  return,  but  understand  from  Dr.  Jewell  that  there  is  some  con- 
traction of  the  orifice,  and  that,  in  all  probability,  it  will  be  necessary  again 
to  divide  its  margins.” — M.] 

ABSENCE  OF  THE  WOMB  AND  MEANS  BY  WHICH  IT  CAN  BE 
ASCERTAINED. 

The  womb  may  be  absent  coincidently  with  absence  of  the  vagina, 
as  in  the  instances  reported  by  Engel,*  Morgagni,!  Baudelocque,f 
Dupuytren,§  Boyer, ||  and  Caillot  ;1T  the  absence  of  the  uterus  may 
also  consist  with  a perfectly  natural  appearance  of  the  external  geni- 
talia : Colombus,**  Lieutaud,tt  and  other  authors  have  noticed  such 
cases  of  uterine  anomaly. 

For  the  purpose  of  ascertaining  that  the  uterus  is  absent,  or  that  it 
exists  only  in  a rudimental  state,  several  authors,  and  among  others 
we  may  mention  Plenck,f±  Morgagni, §§  and  Fodere,||||  have  pointed 
out  the  deficiency  of  the  breasts  and  of  the  menses,  and  the  obturation 
of  the  vagina  at  its  superior  extremity;  but  MetzgerlFIF  very  properly 
remarks  that  these  signs,  which  are  very  far  from  being  always  present 
in  the  cases,  afford  only  presumptive  evidence,  which  is  not  sufficient 
for  the  establishment  of  a positive  diagnosis.  In  fact  the  normal 
development  of  the  external  genital  organs  and  their  appendages  may 
the  more  readily  coincide  with  the  absence  of  the  rudimental  state  of 
the  womb,  inasmuch  as  it  often  happens  as  observed  by  Engel***  and 
Dupuytrenttt  that  the  development  of  the  ovaria  is  quite  complete  in 
these  cases ; and  these  organs  which  are  in  the  female  what  the  testes 
are  in  the  male,  especially  constitute  the  sex  of  the  woman.  Besides, 
Engel,  Dupuytren  and  Professor  Stoltz  have  found  the  womb  absent 
in  women,  or  in  a rudimental  condition,  when  the  breasts  were  per- 
fectly well  formed;  we  have,  ourselves  seen  a woman,  in  good  health, 
and  the  mother  of  a child,  although  she  had  never  been  regular ; 
cases  of  the  same  nature  have  fallen  under  the  notice  of  Zacchias,fff 
Fodere§§§  and  several  other  medico-legal  writers.  Indeed,  the  obtu- 
ration of  the  superior  extremity  of  the  vagina  is  not  to  be  regarded 

* De  Utero  Deficiente  apud  Schlegel,  t.  i.  p.  239. 

j-  Lettre46,  n.  11  and  12. 

* Art.  des  Accouch.  3d  edit.  t.  i.  chap.  3.  p.  168. 

§ Repertoire  d’Anat.  Pathol,  t.  v.  p.  99. 

||  Traite  des  Malad.  Chirurg.,  t.  x.  p.  423. 

T[  Mem.  de  la  Soc.  Med.  d’Emulation,  t.  ii.  p.  470. 

**  Da  re  Anatomica,  lib.  xv.  p.  495. 

-ff  Histoire  Anat.  Med.,  t.  ii.  p.  343. 

Element.  Med.  Chirurg.  Forensis,  i.  p.  3. 

§§  Morgagni,  Lettre  46,  No.  13  and  20. 

HU  Fodere,  Med.  Legale,  2d  edit.  t.  i.  p.  393. 

HIT  Principes  de  Med. Legale, traduitdel’AUemandparleDocteur  J.  J.Ballard,p.  278. 

***  De  Utero  Deficiente,  t.  i.  p.  239. 

Iff  Repertoire  d’Anat,  Pathol.,  t.  v.  p.  99. 

***  Qusestiones  Med.  Leg.,  lib.  iii.  tit.  i.  queest.  2. 

§§§  Med.  Legale,  t.  i.p.  395,  2d  edit. 


ABSENCE  OF  THE  WOMB. 


119 


as  a sign  more  to  be  depended  on  than  the  others  above  mentioned, 
since  Haller,*  Morgagni, t and  NicolonJ  have  spoken  of  women  pos- 
sessing the  womb  itself  though  deprived  of  the  vagina. 

The  best  means  of  making  the  diagnosis  consists  in  introducing  a 
finger  into  the  rectum  and  a sound  into  the  bladder,  which  should  be 
directed  so  as  to  turn  the  convex  part  of  the  instrument  towards  the 
bowel.  By  making  pressure  in  this  way  upon  the  fundus  of  the 
bladder,  it  would  be  an  easy  matter  to  determine  whether  any  inter- 
mediate body  could  be  found  between  the  bladder  and  the  intestine ; 
and  if  any  one  should  be  found,  whether  it  presented  the  character  of 
the  well-formed  womb  or  not.  Professor  Stoltz  recommends,  espe- 
cially in  lean  women,  that  to  the  above  mode  of  exploration,  we  should 
conjoin  that  of  palpation  above  the  pubis.  This  should  be  done  so 
as  to  make  the  fingers  pressing  down  the  hypogaster,meet  the  fingers 
of  the  other  hand  introduced  into  the  vagina.  It  must  be  confessed, 
however,  that  good  modes  of  exploration  are  not  in  every  case  prac- 
ticable, and  that  where  they  can  be  used,  they  may  still,  in  some 
instances,  leave  the  physician  in  a state  of  doubt  as  to  the  exact  degree 
of  the  uterine  development. 

£The  remark  made  in  a preceding  paragraph,  by  the  author,  as  to  the 
woman  who  was  healthy,  and  a mother,  although  she  had  never  been  regular, 
is,  I fear,  calculated  to  mislead  in  an  important  step.  I mean  the  marriage  of 
persons  who  have  never  been  the  subjects  of  menstruation.  Notwithstanding 
the  case  in  question,  I should  esteem  it  a duty  to  recommend  that  marriage 
should  be  postponed  until  after  the  eruption  of  the  menses;  or  at  least  until 
a competent  inquiry  should  be  made  as  to  the  fitness  of  the  subject  to  enter 
into  the  marriage  contract.  The  following  case  is  sufficient  to  confirm  this 
opinion,  and  I cite  it  the  more  willingly  as  showing  not  only  that  coinci- 
dently  with  absence  of  the  womb,  there  may  be  well-formed  mammae  and 
external  genitalia,  but  the  most  perfect  condition  of  the  erotic  principle.  I 
cite  the  case  from  the  Philad.  Prac.  of  Med.,  second  edit.,  p.  67.  Mrs. 

aged  twenty-two  and  a half  years,  was  married  to  her  present  husband 

more  than  two  years  ago.  She  is  of  middling  stature,  of  a fair  complexion, 
and  presents  all  the  exterior  appearances  of  a person  in  perfect  health.  She 
is  not  fat,  but  has  a certain  embonpoint,  a good  figure,  and  a very  feminine 
and  most  agreeable  expression  of  countenance.  She  is,  indeed,  a handsome 
woman.  She  has  never  menstruated ; nor  has  she  suffered  pain  or  any  severe 
attack  of  disease;  says  that,  as  she  did  not  menstruate  at  the  proper  period, 
medical  advice  was  sought,  and  followed  in  the  treatment  of  the  case. 
That  treatment  proved  unsuccessful,  and  she  was  married , with  the  expecta- 
tion (of  her  friends)  that  the  marriage  would  be  followed  by  the  eruption  of  the 
catamenia.  The  mammae  were,  at  the  period  of  the  marriage,  well  developed, 
and  the  pudendum  amply  supplied  with  hair;  indeed, all  the  phenomena  of 

* Disp.  Anatom,  ab  Hallero,  collect,  t.  v.  p.  327. 

t Morgagni,  Lettre  47.  p.  256. 

I Theses  de  la  Faculie  de  Strasbourg,  annee  1808. 


120 


ABSENCE  OF  THE  WOMB. 


a perfect  development  of  the  sexual  system  were  present  except  the  menstrual 
office. 

The  husband  found,  however,  that  some  unknown  cause  acted  as  an 
impediment  to  the  congress,  and  after  more  than  two  years  of  concealment, 
he  consulted  me  upon  the  subject.  * 

An  opportunity  being  allowed  to  me  of  making  a full  investigation  in  the 
presence  of  her  mother,  I found  the  external  organs  perfectly  formed ; the 
mons  large ; the  labia  and  nymphae  as  well  as  the  clitoris  perfect,  and  the  os 
magnum  of  a natural  appearance;  but  the  vagina  was  a mere  cul-de-sac,  not 
more  than  two  inches,  and  probably  less  than  that,  in  length.  Upon  pressing 
the  point  of  the  finger  against  the  bottom  of  the  cul-de-sac,  it  seemed  to  have 
no  connection  with  any  part  above  it. 

I requested  the  lady  to  lie  upon  her  back,  and  introducing  an  index  finger 
as  far  as  possible  into  the  rectum,  I explored  with  it  the  excavation  of  the 
pelvis,  in  order  to  discover  any  tumour,  or  any  organ  that  might  be  contained 
within  the  cavity ; but  as  all  the  tissues  were  ductile  and  very  yielding,  I began 
to  suspect  that  there  might  be  no  womb  at  all  in  the  case.  Therefore,  laying 
the  fingers  of  the  left  hand  upon  the  lowest  part  of  the  hypogaster,  and 
pressing  them  firmly  towards  the  finger  that  was  used  in  exploring  the 
internal  parts,  I found  that  they  could  be  brought  so  near  to  each  other  as  to 
make  it  perfectly  clear  that  there  was  no  womb  in  the  case,  or  I must  have 
felt  it,  so  near  was  the  approximation  of  the  finger  of  the  right  to  those  of 
the  left  hand.  Having,  by  the  most  careful  exploration,  in  this  manner, 
discovered  the  unfortunate  state  of  the  young  lady,  I felt  obliged,  in  a consci- 
entious discharge  of  duty,  to  tell  her  the  whole  truth,  which  I did  in  the  best 
way  I could ; and  yet,  as  may  be  readily  supposed,  the  knowledge  of  her 
situation  was  accompanied  with  all  the  appearance  of  that  violent  distress 
and  agitation  that  might  naturally  flow  from  such  unhappy  circumstances. 

The  aphrodisiac  sense  in  this  lady  is  very  stron g,  which  might  well  be 
the  case  where  the  ovaria  are  fully  developed,  even  though  the  uterus  had 
never  been  evolved  in  her  constitution. 

I was  deeply  impressed  myself  with  the  melancholy  fate  of  two  estimable 
persons  who  would  never  have  placed  themselves  in  so  unhappy  a condition, 
if,  by  a proper  exploration  before  the  marriage,  the  real  state  of  things  could 
have  been  discovered.  The  case  serves  to  show  how  improper  it  is  to  permit 
the  rites  of  marriage  to  be  solemnized  for  persons  who  do  not  possess  all. the 
attributes  properly  belonging  to  the  sexes.  I do  not  contend  that  every  case 
of  failure  to  menstruate  at  the  proper  time  is  indicative  of  the  necessity  for 
exploration  by  the  touch : but  I think  that  no  case  of  extraordinary  protraction 
of  an  emansio  mensium,  and  especially  one  where  any  question  of  courtship 
or  marriage  is  likely  to  arise,  should  be  allowed  to  go  on  without  the  acquire- 
ment by  the  medical  adviser  of  a true  and  perfect  knowledge  of  the  facts  as 
to  the  organization  of  the  parts. — M.] 


LESIONS  OF  SITUATION. 


121 


SECOND  SECTION. 

CHAPTER  VI. 

LESIONS  OF  SITUATION. 

Of  displacements  and  deviations  of  the  genitourinary  organs  in  the  female. 

The  womb,  in  its  natural  state,  being  but  loosely  supported  within 
the  pelvis  by  means  of  its  ligaments,  is  liable  to  a variety  of  displace- 
ments and  deviations  which  affect  its  relations  with  the  other  portions 
of  the  genital  apparatus,  or  with  the  viscera  contained  in  the  cavity 
of  the  abdomen. 

Most  of  the  lesions  of  situation  that  occur  to  the  female  genito- 
urinary organs  have  been  noticed  since  the  remotest  ages,  for  Hippo- 
crates,*  Hristotle, t Hretseus,  Hspasia,  Soranus,  Hntilhis  and  On- 
basins  mention  them  in  their  works,  some  fragments  f of  which  have 
been  communicated  to  our  times  by  He  tilts. 

Hippocrates , who  regarded  a state  of  absolute  celibacy  as  one  of  the 
principal  causes  of  derangement  of  the  catamenia,  and,  consequently, 
of  engorgement  of  the  womb,  has  said  (and  in  that  he  differs  from 
all  modern  authors),  that  women  in  the  conjugal  state,  and  in  whom 
the  womb  does  not  continue  always  void,  are  less  subject  than  virgins 
to  Uterine  disorders:  Hv  yap  ix/xeteat  uatv  at  /xtjtgai  artQTiayvfiJftf  xat  xoiT. t'a 
[xr]  xtvwT!at  oi;  pvjiditi a Otgetyovtal.  Tort'5  ovv  attiov  ytvsfat  coot's  avtaa  %v/x[xvsiv 

oia  /xrj  jiay vsvoixtvrjs  t^j  ywaixo$  ( Hipp . Op.  de  Naturci  Mitlier.)  In  this 
last  respect  the  father  of  medicine  was  in  error,  for  the  displacement 
of  the  sexual  organs  are  much  more  rare  in  virgins  and  sterile  women 
than  in  those  who  are  married  and  who  have  children. 

Where  the  lesions  of  situation  of  the  genitals  are  slight,  they 
scarcely  occasion  inconvenience  to  the  patient ; but  where  they  are 
considerable  and  permanent,  they  are  the  more  worthy  of  attention, 
as  likely  to  result  in  inconvenience  or  accidents,  that  are  beyond  the 
reach  of  medicine.  Although  too  great  a degree  of  mobility  of  the 
womb  is  attended  with  numerous  bad  effects,  its  immobility,  if  to  a 
considerable  degree,  becomes  also  a disturbing  cause,  as  to  the  sur- 
rounding parts,  and  may  prevent  the  womb  itself  from  fulfilling  some 
of  its  appropriate  functions,  such  as  pregnancy  and  labour,  which 
require  considerable  changes  of  its  situation. 

Among  the  lesions  of  position  to  be  treated  of  in  this  section,  we 
place — 

1.  Hysteroptosis  or  prolapsion  of  the' womb. 

2.  Anteversion  and  retroversion. 

* De  Natura  Mulierum.  f Historia  Anomal.,  lib.  vii.  cap.  2. 

* Aetius  Tetrabib.  iv.  serm.  4.  cap.  76  and  77. 


122 


PROLAPSUS  UTERI. 


3.  Anteflexion  and  retroflexion. 

4.  Obliquity. 

5.  Inversion. 

6.  Elevation  of  the  womb. 

7.  Immobility. 

8.  Various  hernias  of  the  womb. 

9.  Hernias  of  the  ovaries. 

10.  Vaginal  cystocele. 

11.  Vaginal  enterocele. 

12.  Vulvar  enterocele  and  cystocele. 

13..  Descent  of  the  internal  membrane  of  the  vagina,  and  invagi- 
nation. 

/ 

OF  HYSTEROPTOSIS. 

Hysteroptosis  * or  falling  of  the  womb,  is  the  displacement  of  the 
viscus  downwards ; and  it  may  be  complete  or  incomplete. 

In  the  former  case  the  organ  escapes  entirely  from  the  pelvis,  and 
may  be  seen  completely  outside  of  the  vulva  ; in  the  latter  case,  on 
the  contrary,  it  projects  more  or  less  considerably  into  the  vagina, 
but  does  not  descend  below  the  inferior  strait. 

Prolapsion  of  the  womb  may  take  place  not  only  during  preg- 
nancy and  after  delivery,  but  also  while  the  womb  is  non  gravid,  for 
it  has  been  met  with  even  in  virgins.t 

The  disease  in  question,  which  M.  Lisfranc  correctly  regards  as 
being  generally  produced  by  engorgement  of  the  womb,  has  been 
divided,  by  most  of  the  writers  on  the  subject,  into  three  degrees  or 
varieties,  which  we  shall  proceed  to  describe. 

In  the  first  degree , which  is  merely  a depression  or  incipient  pro- 
lapsion, the  womb  settles  down  into  the  middle  of  the  vagina,  which 
it  enlarges  in  order  to  make  a lodgment  for  itself  therein.  In  this 
kind  of  displacement,  which  is  but  a slight  affection,  but  that  ought 
to  be  speedily  attended  to,  the  patients  complain  of  dull  pain  in  the 
loins  and  of  a dragging  sensation  about  the  groins ; they  also  com- 
plain of  a sense  of  weight  at  the  fundament,  and  a pressure  that 
becomes  more  painful  by  long  standing  on  the  feet,  or  by  too  long  a 
walk. 

In  the  operation  of  Touching,  the  neck  of  the  womb  is  soon  felt, 
and  the  os  tincse  is  found  to  be  resting  upon  the  posterior  wall  of  the 
vagina,  which  is  thus  completely  obturated,  and  two-thirds  of  its 
upper  portion  are  inverted  like  a finger  of  a glove  turned  partly  in- 
side out.  In  its  new  situation,  the  womb,  as  it  follows  the  direction 
of  the  axis  of  the  inferior  strait,  acquires  a position  totally  different 
from  that  which  it  ordinarily  assumes. 

The  unnatural  tumour  that  projects  from  the  entrance  of  the 

* From  the  Greek  v't t(a  uterus , *rSnt  falling. 

f Displacements  of  the  womb  in  the  virgin  state  are  rarely  met  with,  because  of  the 
small  size  and  lightness  of  the  organ,  and  probably,  also,  because  of  the  constricted 
condition  of  the  vagina  and  surrounding  parts.  Mauriceau,  Saviard,  Monro  and 
De  Graaf  are  the  only  authors  who  have  reported  cases  of  complete  prolapsion  of  the 
womb  in  the  virgin  state. 


PROLAPSUS  UTERI. 


123 


vagina  may  be  easily  raised  upwards  by  the  finger,  but  it  falls  down 
again  as  soon  as  the  support  is  withdrawn,  unless  the  womb  has 
contracted  new  'adhesions  with  the  vaginal  parietes.  The  nature  of 
the  tumour  is  readily  distinguished  by  the  presence  of  the  os  tineas 
and  the  neck  of  the  uterus,  whose  circumference  is  surrounded  by  a 
sort  of  cushion  composed  of  the  vaginal  walls.  By  placing  one 
hand  on  the  hypogastrium  and  touching  with  the  index  of  the  other, 
we  are  enabled,  except  when  the  person  is  very  fat,  which  is  not  com- 
mon in  these  cases,  to  perceive  the  void  left  in  the  upper  part  of  the 
pelvis,  by  the  descent*  of  the  womb  ; and  in  the  same  way  we  may 
discriminate  between  the  prolapsion  of  the  womb,  and  the  elongation 
of  the  cervix,  which  are  sometimes  very  considerable. 

Most  of  the  symptoms  of  prolapsus  in  the  second  stage  are  pro- 
duced by  the  pressure  of  the  womb  upon  the  surrounding  parts,  espe- 
cially the  bladder  and  rectum,  or  by  the  stretching  of  the  uterine 
ligaments.  This  is  put  beyond  question  by  the  fact  that  all  the 
symptoms  are  diminished  by  rest,  and  particularly  by  rest  in  the  hori- 
zontal posture,  whereas  their  violence  is  redoubled  by  standing  and 
walking.  Where  the  displacement  has  been  gradually  produced,  the 
symptoms  attending  it  are  less  severe  than  where  it  takes  place  sud- 
denly ; where  it  is  suddenly  produced,  it  is  frequently  accompanied 
with  long,  protracted  faintings,  violent  floodings,  severe  pain  in  the 
pelvis,  vomiting,  and  sometimes  even  an  intense  attack  of  peritonitis. 
But,  on  the  contrary,  where  the  displacement  takes  place  slowly,  these 
phenomena  are  rarely  observed,  because  the  organs,  having  slowly 
abandoned  their  natural  situation,  become,  in  a measure,  accustomed 
to  the  unnatural  situation  they  have  assumed. 

[Seeing  that  the  womb  is  attached  to  the  rectum  solely  by  the  recto- 
vaginal septum,  and  to  the  bladder  by  the  vesico  and  urethro-vaginal  septum, 
it  is  manifest  that  these  two  septa  furnish  the  sole  means  of  its  vertical  sup- 
port; while  it  is  true  that  the  parts  themselves  depend  upon  other  attach- 
ments for  their  own  firmness  and  ability  to  sustain  the  womb.  I should 
think  that  no  one  would  attribute  to  the  ligamenta  lata  any  other  mechanical 
function  in  the  case  than  that  of  acting  as  a stay,  on  the  right  and  the  left 
sides,  to  the  womb — a stay  by  means  of  which  it  is  kept  in  place  while  the 
woman  lies  on  the  right  side  or  on  the  left  side.  The  ligamenta  rotunda, 
which,  coming  off  from  the  angles  of  the  womb,  pass  out  through  the 
abdominal  canals  to  be  inserted  on  the  sides  of  the  pudendum,  must  be  re- 
garded also  as  merely  a stay,  one  for  each  side,  by  whose  agency  it  is  that 
the  womb  is  not  overset  or  retroverted  every  time  the  bladder  becomes  filled 
with  urine.  These  ligamenta  rotunda  do  not  sustain  the  womb  vertically  at 
all,  but  act  merely  to  restrain  its  tendency  to  retroflexion  and  retroversion. 

Such  being  the  anatomical  facts  in  the  case,  why  is  it  that  falling  of  the 
womb  is  so  common  a malady,  and  on  what  does  the  disposition  to  that 
malady  essentially  depend  ? 

It  has  long  since  seemed  to  me,  that  the  writers  upon  prolapsion  have 
lost  sight  of  one  most  important  element  in  the  pathology  of  the  case,  and 


124 


PROLAPSUS  UTERI. 


that  is,  the  state  of  the  muscles  within  the  pelvis.  They  ought  to  have 
observed  and  remarked  upon  this  important  physiological  law,  viz  : that  the 
diaphragm  has  an  antagonist  force  in  the  floor  of  the  pelvis,  which  is  partly 
muscular,  and  that  where  that  muscular  floor  retains,  together  with  the  other 
tissues  of  the  perineum,  its  full  power  and  energy,  there  can  be  no  prolapsion 
of  the  womb.  The  repeated  distensions  and  dilatations  to  which  the  floor 
of  the  pelvis  is  subjected  in  labour,  cannot  but  tend  to  debilitate  it  and  over- 
come its  power  of  resisting  the  antagonization  of  the  diaphragm  and  abdo- 
minal muscles,  and  as  the  parts  that  sustain  the  womb  depend  for  their  own 
support  on  the  firmness  of  the  tissues  composing  the  pelvie  floor,  it  is  clear 
that  the  womb  may  go  down  with  them  and  it.  But  let  it  be  observed  that 
the  pelvic  floor  itself  is  dependent,  not  merely  upon  its  textural  contractility, 
but  on  the  muscular  power  of  the  levator  ani  muscles — muscles  which 
relax  in  labour,  and  in  defecation,  by  a spontaneous  power  of  relaxation,  in 
order  to  admit  of  the  descent  and  protrusion  of  the  pelvic  floor  in  question, 
and  which  is  restored  to  its  proper  level,  and  drawn  upwards,  and  kept  there 
by  the  sole  power  of  the  levator  muscles.  Hence  it  is,  I think,  clear,  both 
by  reasoning  and  by  observing  clinically  the  facts  in  the  case,  that  the  weak- 
ness and  loss  of  power  of  the  levator  muscles  have  much  to  do  with  the 
pathology  of  prolapsus  uteri. 

It  will  not,  I suppose,  have  escaped  the  observation  of  all  persons  of  ex- 
perience, that  in  bad  cases  of  prolapsus,  the  perineum  is  thin,  feeble  in  its 
tension,  and  that  the  whole  perineum  is  at  a lower  level  than  in  those  who 
do  not  labour  under  prolapsus. 

It  is  essential  to  remark  that  weakness  and  prolapsion  of  the  womb  are  apt 
to  follow  bad  labours,  and  to  be  coincident  with  the  signs  of  general  debility 
of  the  muscular  apparatus  of  the  whole  body.  It  is  not,  indeed,  met  with, 
except  very  rarely,  in  the  strong,  active,  muscular  subject,  and  that  even  in 
these  subjects,  the  prolapsion  is  rather  a state  of  immobility  or  fixedness  of 
the  womb  at  a low  level,  than  a real  prolapsus. 

I fully  agree  with  M.  Colombat  in  his  general  statement  and  rationale  of  the 
symptoms  of  our  case,  but  I would  call  attention  to  the  relations  existing 
betwixt  the  sacral  and  hypogastric  plexuses  of  nerves  and  the  renal  and 
solar*plexuses,  and  indeed  as  extending  to  the  whole  splanchnic  system,  for 
an  explanation  of  the  extraordinary  and  complicated  sympathies  that  are 
awakened  in  prolapsion  of  the  uterus.  M.  Colombat  has  pointed  out,  as 
one  of  the  complications  of  prolapsus,  the  induction  of  intense  peritonitis. 
I have  never  met  with  such  a complication  in  a long-continued  and  very 
extensive  range  of  practice  ; but  I have  met  with  many  cases  simulating 
peritonitis  so  closely  as  to  render  the  diagnosis  very  difficult  indeed.  I refer 
to  the  cases  described  in  the  Pliilad.  Pract .,  at  p.  141,  and  seq.  The  same 
kind  of  observations  havo  been  made  by  W.  Maunsell,  in  his  Dublin  Prac- 
tice of  Midwifery , and,  so  far  as  I know,  by  no  other  authors.  I shall 
reserve  for  a future  page  the  observations  I have  to  make  on  the  treatment 
of  prolapsus  uteri. — M.] 


PROLAPSUS  UTERI. 


125 


As  the  phenomena  that  accompany  falling  of  the  womb  in  the 
second  degree  are  not  always  the  same,  and  may  vary  according  as 
the  distension  of  the  uterine  ligaments  and  the  pressure  of  the  womb 
upon  the  bladder  and  rectum  are  greater  or  less,  we  shall  point  out 
the  symptoms  most  commonly  met  with. 

The  patient  cannot,  without  difficulty,  continue  either  standing  or 
sitting,  and  finds  comfort  only  in  the  horizontal  position.  She  feels 
pain  in  the  groins,  the  loins  and  the  hypogastric  region*  with  a sense 
of  weight  about  the  fundament,  the  perineum  and  vulva;  and, 
lastly,  she  has  a distinct  sense  of  the  presence  of  a large  tumour, 
which,  upon  the  slightest  effort,  seems  as  if  it  would  escape  at  the 
vulva.  Like  womdn  in  labour,  she  is  liable  to  inappetency,  nausea, 
and  even  vomiting,  which  all  proceed  from  the  sympathetic  connec- 
tion of  the  stomach  with  the  womb.  To  these  symptoms  must  be 
added  those  of  constipation,  of  dysuria,  and  even  of  ischuria,  arising 
from  the  pressure  of  the  tumour  upon  the  bladder  and  rectum,  a 
pressure  that  is  greater  and  greater  as  the  tumour  descends  lower  and 
lower  into  the  vagina.  The  irritation  of  the  womb,  produced  by 
this  unnatural  situation,  and  probably,  also,  the  obstruction  thence 
arising  as  to  its  circulation,  often  determine  an  attack  of  inflamma- 
tion, accompanied  by  intense  redness,  and  greater  or  less  swelling 
of  the  uterus. 

Incomplete  descent  of  the  womb  frequently  presents  to  the  medical 
attendant  a degree  of  obscurity  that  it  is  quite  impossible  to  dissipate, 
except  by  means  of  the  Touchy  properly  performed,  and  in  the  man- 
ner to  be  described.  In  the  first  place,  the  woman  must  be  examined 
in  a standing  posture,  because  the  prolapsion  is  then  greater  than  it 
is  in  the  horizontal  position,  in  which  it  may  even  wholly  disappear. 
If  the  patient  is  a late  riser,  the  operation  should  be  deferred  for 
several  hours,  and  then  it  should  not  be  done  until  after  the  bowels 
have  been  evacuated,  as  well  as  the  bladder,  for  the  womb  is  always 
found  to  be  lower  when  these  parts  are  distended  with  their  contents. 
By  attending  to  all  these  points,  and  recollecting  what  we  shall 
further  add  on  the  subject,  we  may  very  readily  ascertain  the  exist- 
ence of  an  incomplete  descent,  and  distinguish  between  it  and  the 
other  affections  with  which  it  is  often  confounded. 

Among  the  disorders  that  give  rise  to  these  mistakes  in  diagnosis, 
may  be  mentioned  elongation  of  the  cervix  uteri,  fungous  tumours 
of  the  cervix,  and  particularly  polypus  of  the  womb,  passing  into 
the  vagina  through  the  mouth  of  the  womb.  The  records  of  the 
science  show  cases  in  which  the  surgeon,  supposing  himself  about  to 
extirpate  a polypus  proceeding  from  the  cavity,  or  growing  from  the 
neck  of  the  womb,  has  completely  extirpated  the  womb  itself,  which 
was  affected  with  prolapsus  in  the  second  stage. 

Such  a mistake  will  be  avoided  by  keeping  in  mind  this  principle, 
that  tumours  composed  of  the  procident  uterus  are  harder  and  more 
sensitive  than  polypus,  and,  besides,  that  the  os  tincse  is  always  to 
be  found  at  the  inferior  extremity  of  the  mass,  and  which  cannot  be 
confounded  with  any  accidental  opening  that  might  happen  to  exist 
upon  the  surface  of  a polypus,  inasmuch  as  a probe  could  not  be 


126 


PROLAPSUS  UTERI. 


made  to  penetrate  so  deeply  into  it  as  into  the  uterine  cavity.  Fur- 
thermore, the  tumour  formed  by  a polypus  is  always  largest  at  its 
lower  extremity,  while  that  constituted  by  a prolapsed  womb  is  a 
cone  with  the  base  uppermost,  and  is  consequently  smallest  below. 

Finally,  in  order  to  dispel  every  remaining  doubt  from  the  mind  of 
the  practitioner,  he  should  remember  that  polypus  of  the  womb  is 
irreducible,  and  that  any  attempt  to  reduce  it  causes  insufferable  pain. 
Prolapsus  uteri  in  the  second  degree  is,  on  the  contrary,  easily  reduci- 
ble, while  its  reduction  gives  great  relief  to  the  patient. 

[I  beg  leave  lo  caution  the  inexperienced  reader  against  confiding  implicitly 
in  this  diagnostic  statement.  I have  met  with  several  samples  of  polypus 
uteri,  that  were  occasionally  within  reach,  and  on  other  occasions  retired 
beyond  the  reach  of  the  index.  It  is  quite  reasonable  to  suppose  that  a pedi- 
culated  polypus  attached  to  the  fundus,  should  sometimes  be  forced  partially 
through  the  os  uteri  under  augmented  muscular  intolerance  of  its  presence, 
and  afterwards  withdrawn  into  the  cavity,  on  the  cessation  of  the  muscular 
spasm. — M.] 

An  incomplete  descent  of  the  womb  does  not  prevent  conception. 
We  had  charge  of  the  case  of  an  itinerant  fish-woman,  who  became 
pregnant  and  was  safely  delivered,  notwithstanding  she  had  a pro- 
lapsus in  which  the  tumour  projected  an  inch  beyond  the  labia. 
While  she  was  lying  down,  the  womb  retreated  as  much  as  eighteen 
or  twenty  lines  within  the  vagina.  Impregnation  might  possibly 
take  place  even  in  a case  of  almost  complete  procidentia,  but  in  such 
a case  the  coitus  must  take  place  directly  within  the  uterus  itself. 

[This  is  a statement  that  I look  upon  as  wholly  incredible. — M.] 

Choppart  cites,  on  the  authority  of  Marignes,  the  instance  of  a 
female,  who  had,  from  the  age  of  fourteen,  been  troubled  with  a pro- 
lapsus that  slowly  increased.  The  husband  of  this  girl  had  no 
children  by  her  until,  after  a considerable  length  of  time,  he  dilated 
the  orifice  of  the  womb,  and  consummated  the  act  of  generation  in 
its  very  cavity.  The  pregnancy  was  in  all  respects  natural,  but  at 
the  time  of  her  confinement,  they  were  compelled,  on  account  of  the 
rigidity  of  the  os  uteri,  to  make  two  incisions  into  it  on  opposite  sides ; 
after  which  the  child  was  born  dead,  and  the  mother  recovered  with- 
out difficulty. 

[Such  relations  as  the  above  require  a stronger  confirmation  before  they 
should  be  deemed  credible.  They  are  necessarily  hypothetical  as  to  the 
important  steps  of  the  doctrine. — M.] 

Several  authors,  among  whom  I may  mention  Haller*  (quoting 
Kalm,)  Paul  Portalf  and  Nauche,f  have  reported  instances  of  prolap- 
sus uteri  occurring  during  pregnancy;  Mauriceau,§  Paul  Portal ||  and 

* Disputat.  Chirurg.  Select.  Haller,  t.  iii.  p.  587. 

f La  Prat.des  Accouch.  Sout.  d’un  Grand  Nombre,  d’Observations,  Observ.  x. 

* Malad.  propres  aux  Femmes,  t.  i.  p.  85. 

§ Obs.  sur  la  Grossesse  et  1’ Accouch.,  Obs  vi. 

I Loc.  citat.  Observ.  x. 


PROLAPSUS  UTERI. 


127 


Brodmann*  have  noticed  cases  in  which  incomplete  and  reducible  hys- 
teroptosis, after  having  disappeared  in  the  first  months  of  pregnancy, 
has  returned  towards  the  conclusion  of  it,  and  even  during  labour  itself. 
In  the  cases  by  Garint  and  Ducreux,f  the  prolapsus  seems  to  have 
taken  place  without  any  antecedent  falling  of  the  womb,  and  at  the 
very  time  of  the  parturient  efforts.  In  some  instances,  the  womb  has 
remained  until  the  end  of  the  labour,  partly  within  and  partly  outside 
of  the  pelvic  cavity.  Wagner§  and  Choppart||  each  relate  an  instance 
of  this  kind.  Finally,  the  prolapsion  has,  in  some  examples,  been 
spontaneously  reduced  at  the  approach  of  labour ; as  in  the  cases 
published  by  Loder,1T  Saviard,**  Portaltt  and  Choppart. 

Whenever  an  incomplete  hysteroptosis  becomes  complete,  then 
all  the  symptoms  caused  by  the  compression  of  the  bladder  and  rec- 
tum immediately  diminish  and  the  evacuation  of  urine,  and  by  stool 
take  place  without  any  difficulty.  However,  while  the  symptoms 
partly  disappear,  they  are  succeeded  by  increased  intensity  of  the 
symptoms  resulting  from  the  stretching  and  distension  of  the  perito- 
neal ligaments,  and  by  numerous  other  symptoms  which  we  shall 
detail  in  speaking  of  complete  falling,  or  procidentia  of  the  womb. 

In  this  third  degree  of  hysteroptosis,  the  entire  body  of  the  womb 
has  passed  out  beyond  the  vulva,  and  the  whole  organ,  which  is  seen 
movable  and  suspended  betwixt  the  woman’s  thighs,  has  dragged 
down  in  its  fall  not  only  the  vagina  that  is  inverted,  but  also  the  uterine 
appendages,  the  bladder,  and  a portion  of  the  rectum.ff  The  displace- 
ment of  these  organs  soon  forms  a cul-de-sac  filled  with  the  convolu- 
tions of  the  small  intestines  giving  rise  to  another  tumour  of  greater 
or  less  magnitude,  which  prevents  the  reduction  of  the  womb  itself. 

The  distance  to  which  the  womb  projects  forth,  is  equal,  in  some 
samples,  to  6,  8,  or  even  10  inches, §§  and  the  tumour  is  either  strangu- 
lated, oval,  or  globose;  but  most  commonly  conoidal,  and  fills  up  the 
whole  orifice  of  the  vulva  whose  labia  seem  elongated  by  the  presence 
of  the  foreign  body  which  keeps  them  always  disparted. 

Whatsoever  the  form  of  the  procident  womb,  the  cervix  uteri  is 
always  to  be  seen  with  its  orifice  very  much  contracted, ||||  rounded  or 
semilunar,  and  generally  discharging  a mucous  substance,  and  even 
the  mensual  fluid,  at  the  catamenial  periods. 

* Ephem.  decur.  ii.  an  3 p.  368.  + Journal  de  Med.,  t.  iv.  p.  165. 

* Mem.  de  l’Acad.  de  Chirurg.,  t.  viii.  p.  493. 

§ Biblioth.  Med.,  t.  xiii.  p.  114. 

||  Traite  des  Mai.  des  Voies  Urinaires,  t.  ii.  p.  73. 

1 Jour,  fur  die  Chirurgie,  vii.  p.  13. 

**  Mem.  de  l’Acad.  de  Chirurg.,  t.  iii.  et  Observ.  Chirurgicales. 

ff  Journal  de  Med.  xlv. 

The  autopsies  and  cases  published  by  Kerckriug  (spicileg.  Anat.contin  observ. 
rariorum) — Boehmer,  (in  Disput.  Chir.  Haller,  t.  iii.  557) — Kalm,  (ed.  pag.  588) — 
Ruysch  (Obs.  Anat.  viii) — 1.  Cloquet , (Theses  de  Concours,  Paris,  1831,) — prove  con- 
clusively that  the  inverted  vagina  dragged  down  by  the  womb,  contains,  within  the 
sort  of  cul-de-sac  thus  formed,  a portion  or  the  whole  of  the  adjoining  organs. 

§§  Mauriceau,Saviard,  Ruysch  and  Horn,  give  cases  of  complete  prolapsus,  in  which 
the  tumour  descended  to  the  middle  of  the  thighs. 

fl||  Boehmer,  Disp.  Chir.  Haller,  t.  iii.  p.  558,  says,  Orificium  uteri  ita  angustum,  ut 
vix  ac  ne  vix  quidem,  acu  in  cavtatem  uteri  peuetrare  potuerimus. 


12S 


PROLAPSUS  UTERI. 


It  sometimes  happens  that  the  womb  thus  displaced,  becomes 
affected  with  violent  pain,  and  gives  rise  to  copious  haemorrhage;  the 
tumour  that  it  constitutes  from  being  always  bathed  with  urine  and 
irritated  by  the  constant  friction  of  the  thighs  and  the  dress,  becomes 
inflamed,  swollen,  excoriated,  and  often,  indeed,  wholly  or  partially 
gangrenous.  It  is  found,  on  other  occasions,  that  the  unreduced 
tumour  becomes  a chronic  disease;  and  the  internal  membrane  of  the 
vagina  that  lines  it,  from  being  exposed  to  continual  friction  and  to 
the  air,  assumes  the  appearance  of  the  skin ; so  that  the  womb  has 
been  actually  mistaken  for  the  male  organ;  and  the  woman  so  situ- 
ated, has  been  looked  upon  as  an  hermaphrodite.  Saviard,  whose 
inclinations  led  him  to  the  collecting  of  the  rarest  and  most  interesting 
cases  in  his  art,  has  handed  down  among  his  cases  as  arranged  by 
Devaux,  the  history  of  a girl  at  Toulouse  who  passed  for  an  her- 
maphrodite, and  who  was  merely  the  subject  of  a complete  procidentia 
uteri.'*  The  celebrated  surgeon  of  Charles  IX.,  the  ingenious  Am- 
brose Pare,  relates  that  a woman,  in  order  to  excite  pity  and  procure 
a more  abundant  alms,  had  simulated  a procidentia  uteri  by  means  of 
a bladder  half  filled  with  air  and  begrimed  with  blood  which  she 
adjusted  by  means  of  a sponge  attached  to  it  and  introduced  within 
the  vagina. 

The  reason  why  prolapsus  is  so  rare  among  virgins,  and  is  indeed 
hardly  met  with,  except  among  women  who  have  borne  children, 
and  chiefly  in  such  as  have  had  repeated  confinements  is,  that  during 
pregnancy  the  ligaments  of  the  womb  become  considerably  stretched, 
and  but  slowly  recover  their  natural  condition  subsequently  to  the 
lying-in.  By  reflecting  upon  this,  and  by  also  recollecting  that  the 
womb  is  much  larger  and  heavier  after  a labour  than  it  is  in  the  non- 
gravid  state,  we  may  comprehend  why  displacements  of  the  womb 
are  so  frequent,  and  so  easy  to  be  brought  about,  in  the  first  days  that 
follow  the  child-birth,  especially  in  women  who  have  been  delivered 
whilst  standing  up,  or  who  have  risen  too  soon  after  their  lying-in. 

The  predisposing  causes  of  prolapsus  uteri,  are  : Congenital  ca- 
paciousness, or  brevity  of  the  vagina ; a pelvis  of  excessive  dimen- 
sions, either  actually,  or  from  the  want  of  a proper  embonpoint; 
reiterated  pregnancy ; engorgement  of  the  uterus  ; scirrhous,  fibrous 
or  steatomatous  tumours  formed  upon  the  womb,  or  upon  the  mons 
veneris,  as  in  the  case  mentioned  by  Wagner  ;t  the  abusus  coitus, 
chronic  inflammation,  and  the  natural  or  the  accidental  relaxation  of 
the  peritoneal  expansions,  by  which  the  womb  is  attached  to  the  pel- 

* This  young  fine  girl  named  Marguerite  Malaure,  had  been  condemned  by  the 
magistrates  of  Toulouse  to  wear  the  male  dress;  her  sex  was  restored  to  her  by 
Saviard,  who  reduced  the  tumour  that  had  given  rise  to  this  strange  mistake;  after 
which  she  was  enabled  to  dress  herself  in  a female  dress  which  she  had  been  forbid- 
den to  wear.  It  is  probable  that  this  complete  procidence  of  the  womb  was  congenital, 
for  she  said  she  /tad  never  known  herself  to  be  different^.  Dr.  Duval  made  a mistake 
of  the  same  sort,  but  still  less  excusable,  for  the  woman  who  gave  rise  to  it  had  pro- 
lapsus only  in  the  second  degree. 

f Biblioth.  Med.,  t.  xiii.  p.  114.  In  Wagner's  case,  the  womb  had  been  depressed  by 
an  enormous  tumour  on  the  mons  veneris,  and  had  yielded  to  an  impulse  communi- 
cated from  above  downwards,  of  sufficient  power  to  cause  the  uterus  to  yield,  but 
insufficient  to  sink  the  tumour  along  with  it  into  the  cavity  of  the  pelvis. 


PROLAPSUS  UTERI. 


129 


vis,  to  the  rectum  and  to  the  bladder.  Finally,  a chronic  and  profuse 
leucorrhosa,  a lymphatic  temperament,  living  in  a low,  damp  situation, 
and  especially  a sudden  or  habitual  state  of  emaciation ; these  pre- 
dispose to  prolapsus  of  the  womb. 

The  occasional  causes  are  not  less  numerous.  Thus,  these  disor- 
ders are  most  common  among  the  inferior  classes  of  the  population, 
in  Avhich  the  women  are  obliged  to  be  more  upon  their  feet,  walk, 
more,  and  use  violent  exercise  shortly  after  their  confinement.  Falls 
upon  the  feet,  upon  the  seat  or  on  the  hypogastrium  ; pressure  on  the 
lower  belly  by  tight  dresses  or  lacing ; violent  efforts  in  raising  of 
burthens,  or  in  carrying  them  for  a long  time  resting  against  the 
abdomen,  as  is  the  case  with  the  itinerant  saleswomen  of  Paris ; the 
jolting  of  a carriage ; in  a word,  all  motions  requiring  frequent  and 
powerful  contractions  of  the  diaphragm  and  abdominal  muscles ; 
such  as  straining  at  stool  or  in  vomiting,  in  passing  the  urine,  in 
coughing,  sneezing,  singing,  dancing,  wrestling,  leaping,  riding  on 
horseback ; any  of  these  may  be  occasional  causes  of  the  affection 
under  discussion. 

Abortion  ; violent  labour  pains,  particularly  in  labours  where  the 
woman  stands  on  her  feet;  traction  and  imprudent  manoeuvres  in  the 
extraction  of  the  child,  or  placenta ; the  hurry  that  women  are  in  to 
sit  up  and  walk  about  soon  after  parturition,  and  before  the  uterine 
ligaments  have  had  time  to  recover  their  firmness  ; all  these  causes, 
indeed,  give  rise  to  the  various  degrees  of  prolapsus  uteri. 

When  left  to  nature  alone,  a falling  of  the  womb  may  soon  become 
quite  incurable,  for  its  tendency  always  is  to  increase,  and  the  chances 
of  success  are  always  more  unfavourable  as  the  case  is  of  longer  date, 
the  descent  greater,  and  the  concomitant  circumstances  more  disad- 
vantageous. The  sequelae  of  this  disorder,  even  when  complete, 
might,  perhaps,  never  compromise  the  life  of  the  patient,  were  it  not 
for  the  complications  that  are  often  the  effects  as  well  as  the  causes 
of  the  principal  lesion  ; complications  that  always  aggravate  the  prog- 
nosis, which  of  itself  is  bad  enough.  Thus,  a descent  and  relaxation 
of  the  vagina ; a deformity  of  the  pelvis  ; a dropsy  ; a state  of  maras- 
mus ; the  presence  of  a scirrhus  upon  the  cervix  uteri,  or  of  polypus 
in  the  cavity  of  the  womb,  or  of  a foetus  in  utero  ; a calculus  in  the 
bladder,  are  so  many  complications  changing  the  indications  of  treat- 
ment, always  to  the  disadvantage  of  the  patient,  and  liable  to  become 
fatal,  not  only  by  preventing  the  reduction  of  the  tumour,  but  also 
by  necessitating  certain  operations  and  certain  peculiar  cares  that 
will  soon  require  our  attention. 

In  those  unfortunate  cases  that  are  beyond  the  resources  of  medi- 
cine, and  where  the  physician  is  compelled  to  be  a sad  and  impotent 
spectator  merely,  there  is  nothing  to  be  done  beyond  the  suggestion 
of  measures  of  palliation,  and  feeble  remedies,  which,  for  the  most 
part,  give  but  little  relief. 

The  treatment  of  hysteroptosis  offers  two  indications  : the  first  is 
to  replace  the  organ  in  its  natural  position ; and  the  second  is  to  pre- 
vent the  recurrence  of  the  displacement. 

For  the  most  part,  it  is  an  easy  matter  to  restore  the  womb  to  its 
9 


130 


PROLAPSUS  UTERI. 


natural  position,  where  the  prolapsus  is  in  the  first  or  second  stage, 
and  unaccompanied  with  any  complication.  All  that  is  necessary 
for  this  purpose  is  to  make  the  patient  lie  upon  her  back  so  as  to 
have  the  pelvis  somewhat  higher  than  the  head,  while  the  abdominal 
muscles  are  allowed  to  be  as  much  relaxed  as  possible.  The  womb 
will  then  take  its  natural  position,  and  the  reduction  be  so  much  the 
more  readily  effected,  if,  by  the  introduction  of  two  of  the  fingers 
into  the  vagina,  we  gently  push  the  womb  towards  its  proper  place 
in  the  cavity  of  the  pelvis. 

After  the  reduction,  provided  no  symptoms  of  inflammation  of  the 
organ  are  left,  it  is  frequently  found  useful  to  prescribe,  with  a view 
to  the  radical  cure,  the  use  of  cold  astringent  injections,  to  be  repeated 
twice  or  thrice  a day.  They  may  consist  of  liquor  plumbi  acetas,  or 
a solution  of  one  or  two  drachms  of  alum  in  a pint  of  water  or  of  de- 
coction of  cinchona,  or  of  the  roots  of  the  comfrey,  bistort,  tormentil, 
pomegranate  rind,  or  any  other  astringent  substance.  River  bathing 
in  summer,  and  sulphurous  douches  and  injections  may  be  employed 
at  a later  period,  as  means  for  consolidating  the  cure. 

Generally  speaking,  as  the  simple  depression  of  the  womb  or  pro- 
lapsus in  the  first  stage  produces  but  slight  inconvenience,  it  hap- 
pens that  the  natural  but  unreasonable  delicacy  of  the  female  makes 
her  fearful  of  confiding  her  complaint  to  the  medical  attendant,  pre- 
ferring to  leave  in  the  hands  of  nature  the  care  of  a malady  of  whose 
evil  tendencies  she  is  ignorant.  But  as  the  mischief  has  a tendency 
to  increase  and  extend,  the  malady  becomes  aggravated,  the  suffer- 
ings of  the  patient  increase  daily,  and  a simple  depression  soon  be- 
comes a positive  failing,  and  finally  a complete  procidentia. 

There  are  women  who  conceal  this  disgusting  and  painful  in- 
firmity for  years  together,  and  even  attain  to  an  advanced  age  with- 
out any  very  serious  symptoms.  But  there  are  others  in  whom  the 
womb  cannot  be  reduced,  either  in  consequence  of  its  having  formed 
adhesions,  or  from  its  containing  within  its  cavity  a foetus  of  several 
months,  or  from  other  insurmountable  obstacles,  or  such  at  least  as 
are  connected  with  circumstances  that  may  lead  to  the  sudden  death 
of  the  patient.  We  shall  shortly  point  out  the  course  to  be  taken  in 
those  rare  and  distressing  cases  in  which  all  attempts  at  reduction 
prove  to  be  vain. 

There  is  always  much  greater  difficulty  in  effecting  the  reduction 
of  a complete  hysteroptosis  than  of  one  in  the  first  or  second  stage. 

Where  the  womb  has  escaped  completely  from  the  vulva,  it  is 
proper,  before  proceeding  to  the  reposition,  that  the  patient  should 
empty  the  bladder  and  rectum,  either  spontaneously  or  by  means  of 
the  catheter,  and  the  common  enema.  Provided  the  uterine  tumour, 
as  frequently  happens,  should  be  found  painful  and  sore  from  the 
action  of  the  air,  the  urine,  or  the  friction  of  the  clothing,  emollient 
poultices  ought  to  be  applied  to  it,  and  the  swelling  should  be  re- 
duced by  general  remedies,  such  as  fomentations,  baths,  venesection, 
dieting,  diluent  drinks,  a mild  regimen,  laxatives,  &c.  Such  mea- 
sures as  these  are  particularly  indicated  in  chronic  cases  of  falling  of 
the  womb. 


PROLAPSUS  UTERI. 


131 


After  the  parts  have  been  brought  into  a condition  more  favoura- 
ble for  the  reposition,  the  woman  should  be  directed  to  lie  down  in  a 
position  more  inclined  even  than  that  recommended  in  incomplete 
prolapsus:  the  surgeon,  after  having  anointed  his  fingers  as  well  as 
the  tumour  itself  with  cerate  or  oil,  should  seize  it  with  his  right  hand, 
and,  giving  a few  rotary  movements,  in  a gentle  manner,  and  then 
elevating  and  depressing  it  by  turns,  should  press  it  backwards  into 
the  cavity  of  the  pelvis,  following  the  direction  of  the  axis  of  the 
inferior  strait,  meanwhile  using  the  fingers  of  the  left  hand  at  the 
labia  to  facilitate  the  return  of  the  womb  into  the  body. 

As  soon  as  the  upper  part  of  the  womb,  which  is  largest,  has 
passed  within  the  vulva,  the  rest  of  the  tumour,  being  smaller,  rea- 
dily follows  to  take  its  natural  position  in  the  body. 

Should  the  size  of  the  tumour,  augmented  by  being  in  a state  of 
inflammation,  by  the  thickening  of  its  tissues,  or  by  infiltration,  seem, 
notwithstanding  the  measures  above  recommended,  to  be  so  great  as 
to  make  its  reduction  appear  too  difficult,  we  ought  to  suspend  our 
efforts,  and  wait,  in  order  to  try  new  measures,  to  have  recourse  to 
a prolonged  rest  in  the  horizontal  posture,  and  to  all  the  therapeuti- 
cal aids  calculated  to  combat  the  complications  of  the  case.  We 
should  not  again  attempt  the  reduction  until  some  improvement, 
some  manifest  diminution  of  the  sensibility  and  size  of  the  tumour 
should  invite  to  the  operation.  In  endeavouring  to  restore  the  womb 
to  its  natural  situation,  should  we  still  meet  with  great  difficulties,  and 
have  greater  reason  to  dread  the  induction  of  an  inflammation  more 
dangerous  than  a permanent  procidentia,  it  would  be  a duty  to 
renounce  all  such  attempts,  and  remain  content  with  a treatment 
merely  palliative. 

A medical  man  ought  not,  however,  lightly  to  renounce  all  hopes 
of  reducing  a hysteroptosis,  no  matter  how  severe  nor  of  what 
old  standing.  Saviard  succeeded  in  reducing  Margaret  Malaure’s, 
which  was  congenital.  Several  other  surgeons,  as  mentioned  by 
Sabatier,*  and  among  them  Mauriceau,  Saviard,  Horn  and  Leblanc, 
were  successful  in  the  reduction  of  frighful  cases  of  prolapsus,  the 
size  of  which  had  been  first  reduced  by  means  of  prolonged  rest, 
dieting,  baths,  bleeding,  emollients,  &c.  Dr.  Leveille  and  Dr.  Bobe — 
Moreau,  ( Bull . de  la  Facullt  de  Med.,  1815,  No.  4,) — rendered  pro- 
lapsus of  long  standing  reducible  by  means  of  pressure  with  a ban- 
dage en  doloire.  However,  let  us  remember  the  counsel  already 
given,  not  to  insist  upon  attempts  to  reposit  when  too  many  obstacles 
are  met  with.  Improvident  and  ill-advised  manoeuvres  have  brought 
on  fatal  disease,  such  as  acute  peritonitis  and  metritis.  ( Nouvell 
Bibliot.  Med.,  deuxieme  annee,  tom.  iv.  p.  215.) 

After  having  made  use  of  the  preliminary  treatment  above  recom- 
mended, if  reiterated  attempts,  vainly  made,  should  render  it  evi- 
dently impossible  to  restore  the  womb  to  its  place,  we  must  rest 

* Sabatier,  in  the  Mem.  de  l’Acad.  de  Chir.,  t.  iii.  p.  375,  says  that  “there  is  no 
case  of  procidentia  of  the  womb  that  cannot  be  reposited,  no  matter  how  large  it  ma)- 
be;  but  this  talented  practitioner  admits  that  it  is  not  always  possible  to  keep  it  in 
place  after  reposition.” 


132 


PROLAPSUS  UTERI. 


content  with  giving  due  support  to  the  tumour  by  means  of  a proper 
suspensory,  which  should  be  anointed  with  cerate,  in  order  to  obviate 
the  evil  effects  of  the  friction  of  the  material. 

As  a means  of  more  perfectly  obviating  this  inconvenience,  we 
have  recommended  and  have  made  use  of  a bandage  of  oiled  silk, 
doubled,  the  surface  of  which,  being  smooth,  produces  less  friction 
than  even  the  finest  linen ; and  the  material  is  desirable,  since  it  may 
be  cleansed  several  times  a day,  while  its  impermeability  protects 
the  womb  from  the  painful  excoriations  which  the  constant  contact 
of  the  urine  tends  to  produce. 

Should  the  procidentia  take  place  at  an  advanced  stage  of  preg- 
nancy, the  reduction  of  the  womb  ought,  nevertheless,  to  be  at- 
tempted, and  may  be  easily  effected  at  an  early  stage,  particularly  if 
the  attempt  be  not  long  deferred.  We  have  already  advised  that  the 
bladder  and  rectum  should  be  emptied  before  the  institution  of  any 
attempts  to  reposit,  and  it  ought  not  to  be  forgotten  that  the  intro- 
duction of  the  catheter  is  not  always  an  easy  matter,  from  the  dis- 
tortion of  parts  produced  by  the  descent.  In  some  of  the  cases,  the 
female  catheter  will  not  answer  at  all,  and  we  must  have  recourse 
to  the  male  catheters,  using  the  instrument  with  the  concavity  to- 
wards the  hvpogastrium. 

Where  pregnancy  is  already  in  an  advanced  state,  the  case  of  long 
standing,  and  the  reduction  difficult,  it  would  be  the  dictate  of  pru- 
dence to  abandon  ail  attempts  that  might  prove  hurtful  either  to 
the  mother  or  child  :*  in  such  cases,  it  is  sufficient  to  give  proper 
support  to  the  womb  by  means  of  such  a suspensory  as  has  been 
mentioned,  and  make  the  patient  observe  the  horizontal  position,  in 
bed.  When  the  pregnancy  has  reached  its  full  term,  the  escape  of 
the  foetus  may  be  facilitated  by  gradually  dilating  the  os  uteri;  and 
the  placenta  should  be  removed  by  the  introduction  of  the  hand  into 
the  womb,  so  as  to  take  it,  and  not  by  pulling  at  the  cord. 

[I  cannot  avoid  remarking  upon  this  passage,  that  in  the  vast  majority  of 
cases  of  parturition,  the  placenta  is  expelled  from  the  womb  by  the  sponta- 
neous contraction  of  the  organ,  and  that  no  very  slight  motive  should  be 
allowed  to  operate  on  us  as  inducing  us  to  force  the  womb  for  the  delivery  of 
the  placenta.  I think  the  attendant  should  wait  a proper  length  of  time  for 
the  spontaneous  expulsion,  as  in  a common  healthful  labour.  When  that 
time  has  elapsed,  he  may  properly  carry  his  hand  into  the  womb  in  search 
of  the  after-birth. — M.] 

After  the  birth  of  the  child,  the  reposition  may  be  the  more  easily 
effected,  as  the  womb  has  been  suddenly  reduced  in  size,  and  its 
strong  and  reiterated  contractions  constringe  its  parietes. 

Should  the  procidentia  take  place  during  the  progress  of  a labour, 

* Mauriceau  (Obs.67  and  95)  reduced  one  at  the  fourth  or  fifth  month;  and  Giroud 
likewise  succeeded  not  more  than  ten  days  before  the  labour  came  on.  (M.  Duges 
and  Mad.  Boivin.)  M.Capuron  (Mai.  des  Femmes,  p.  301)  has  shown  that  the  womb 
may  be  irreducible  after  the  first  months  of  gestation,  and  that  the  uneasiness  arising 
from  this  irreducibility,  may  bring  on  abortion. 


THE  PESSARY. 


133 


it  would  be  equally  dangerous  as  in  the  case  above  treated  of,  to 
attempt  its  reduction  ; but  we  should  try  to  hasten  the  delivery  of 
the  child  by  dilating  the  mouth  of  the  womb,  and  by  sustaining  the 
prolapsed  organ.  The  extraction  of  the  placenta  ought  to  be  done 
as  before  recommended,  that  is  to  say,  by  introducing  the  hand  into 
the  womb,  and  acting  in  the  direction  from  the  circumference  to  the 
centre.  When  the  child  is  born,  the  reposition  may  be  effected  with 
little  difficulty. 

Before  closing  our  remarks  upon  prolapsus  in  pregnant  women, 
we  ought  to  state  that  it  almost  always  occasions  an  attack  of 
suppression  of  urine,  that  may  be  relieved  by  passing  up  a finger 
behind  the  symphysis  pubis,  and  pushing  back  the  womb  so  as  to 
take  off  the  pressure  from  the  neck  of  the  bladder  and  the  urethra. 
It  will  be  well  to  point  out  this  mode  of  relief  to  patients  so  situated; 
they  can  make  use  of  it  until  the  time  arrives  when  the  womb  shall 
have  acquired  magnitude  sufficient  to  keep  it  above  the  brim,  which 
generally  happens  about  the  fourth  or  fifth  month. 

At  whatsoever  period  it  may  be  that  the  reduction  is  effected, 
there  always  remains  an  indication  that  it  is  essentially  necessary 
to  fulfil — that  of  preventing  the  escape  of  the  organ,  by  the  use  of  the 
tampon  and  pessaries,  of  different  shapes,  dimensions  and  materials. 

These  supporting  instruments  are  not  absolutely  indispensable 
where  the  affection  is  recent  and  has  suddenly  happened,  but  they 
are  for  the  most  part  so,  where  the  woman  is  of  large  size  and  the 
disorder  of  an  ancient  date. 

OF  PESSARIES  AND  THEIR  VARIETIES. 

The  term  pessary*  is  given  to  an  instrument  designed  to  be  placed 
within  the  vagina,  either  to  maintain  the  reduction  of  a hernia  in  the 
part,  or  to  prevent  the  falling  or  inversion  of  the  organ  itself,  or  what 
is  most  commonly  the  case,  to  prevent  the  prolapsion  and  deviation  of 
the  womb  itself. 

The  use  of  pessaries,  in  the  treatment  of  displacements  of  the 
genito-urinary  organs,  is  of  the  highest  antiquity;  the  Egyptians,  the 
Greeks,  the  Romans,  the  Arabians,  and  all  the  ancient  physicians, 
without  excepting  Hippocrates  himself,  made  much  greater  use  of 
them  than  the  moderns,  because  they  employed  them  not  only  as 
mechanical  and  chirurgical  measures,  but  as  topical  medicaments, 
which  they  varied  according  to  the  supposed  nature  of  the  affection 
they  wished  to  combat ; thus,  they  prepared  pessaries  which  were 
emollient,  astringent,  tonic,  emmenagogue,  anti-hasmorrhagic,  &c., 
according  to  the  indication  to  be  fulfilled. 

The  employment  of  the  pessary  as  a topical  medicament  has,  for  a 
long  time  past,  fallen  almost  wholly  into  neglect,  and  it  is  now  used 
solely  as  a remedy  for  the  displacements  and  deviations  of  the  genito- 
urinary organs  of  the  female  as  before  stated. 

The  ancients  composed  their  pessaries  of  various  substances,  such 
as  wool,  the  leaves  of  plants,  lint  or  rolled  linen,  to  which  they  at- 


From  macros,  derived  from  the  verb  maaw,  to  soften,  to  retain,  to  keep  in  place. 


134 


THE  PESSARY. 


tached  a string  for  the  purpose  of  extracting  them  when  necessary.  At 
a later  age  they  made  use  of  gums,  resins  or  wax,  which  were  softened 
so  as  to  give  them  the  proper  shape.  The  Arabians,  among  whom  we 
may  mention  Albncasis ,*  in  order  to  support  the  womb,  made  use  of 
a small  sheep’s  bladder  filled  with  air,  or  with  a substance  called  coto 
( impleatur  coto)  which  was  left  within  the  vagina  until  the  cure  was 
completed.  Professor  Osiander,  in  his  Compendium  of  Midwifery , 
recommends,  in  imitation  of  the  Arabians  and  of  Apsyrt.es,  the  intro- 
duction into  the  vagina  of  a small  sac  or  bag  made  of  fine  linen,  to 
be  first  filled  with  tan,  and  then  soaked  in  rough  wine. 

Other  authors  have  prescribed  the  introduction  within  the  vagina 
of  a fine  sponge  of  a cylindrical  or  oval  shape,  well  smeared  with 
some  unguent,  and  supported  by  a bandage.  Pessaries  are  also  con- 
structed of  more  solid  materials  of  various  sorts;  such  as  light  kinds 
of  wood,  as  linden  or  cork ; of  hard  woods,  such  as  the  service  tree 
and  the  box  ; animal  substances,  as  horn,  ivory,  wax  or  leather;  and 
lastly,  metals,  particularly  gold,  silver,  copper,  lead  and  tin. 

As  these  substances  used  alone  did  not  fulfil  all  the  desirable  pur- 
poses, they  have  been  combined,  in  order  to  improve  their  qualities. 
Cork,  for  example,!  possessed  the  advantage  of  being  light,  elastic  and 
firm,  but  it  was  too  porous,  and  readily  imbibed  the  mucus  and  other 
fluids  of  the  parts  in  contact  with  them.  This  was  so  much  the  greater 
an  inconvenience,  since  the  fluid  retained  in  the  interstices  of  the  cork 
rapidly  underwent  putrefaction,  gave  rise  to  a disgusting  odour,  and 
to  a variety  of  symptoms  more  or  less  to  be  deprecated.  Roussel  ( Be 
Partu  Cxsareo ) relates  that  a woman  who  was  under  his  care  for 
an  inflammation  of  the  bladder  and  womb,  was  not  relieved  of  her 
pains  and  other  morbid  symptoms  until  after  the  discharge  from  her 
vagina  of  several  bits  of  rotten  cork,  portions  of  an  old  pessary  that 
had  been  adjusted  eighteen  years  before.  Sabatier  [Mem.  de  VAccid. 
de  Chir .,  t.  iii.)  says  that  M.  Grammont  communicated  to  the  academy 
the  case  of  a lady  under  treatment  for  putrid  fever  and  inflammation 
of  the  bowels  produced  by  a cork  pessary  that  had  rotted  in  the  vagina. 
Delamotte  (Mem.  de  l’ Acad.  de  Chir.,  t.  ii.)  also  repeats  that  in  order 
to  relieve  the  violent  pain  of  a lady  under  his  care,  he  was  compelled 
to  extract  a cork  pessary  that  she  had  worn  for  three  years,  and  in 
doing  so  made  use  of  instruments  which  required  all  his  strength  in 
making  the  extraction.  He  adds  that  he  was  ignorant  of  the  cause 
of  the  difficulty  until  he  had  extractedthe  pessary,  which  was  petrified, 
“so  that  the  pessary  resembled  a very  large  urinary  calculus.” 

With  a view  to  prevent  the  imbibition  of  fluids,  the  cork  pessary 
was  covered  with  a thick  coating  of  virgin  wax,  which  certainly  les- 
sened the  objections  to  the  material  and  preserved  it  for  a considerable 
time  from  change.  With  the  same  end  in  view  the  linden  wood 
is  coated  with  varnish  of  different  sorts. 

* Albucasis,  lib.  iii.  cap.  xix.  Quando  frangitur  vulva  mulieris. 

f It  was  especially  in  Levret’s  time  that  the  cork  pessary  was  put  in  vogue.  That 
celebrated  physician  not  only  bestowed  upon  them  the  highest  commendation,  and 
preferred  them  to  all  other  kinds,  but  he  also  at  great  length  described  the  mode  of 
preparing  them  in  a memoir  published  in  the  XXXIV  vol.,  p.  428,  of  the  Aucien 
Journal  de  Medecine. 


THE  PESSARY. 


135 


Ivory  and  the  hard  woods  are  too  heavy,  and  injure  the  parts  by 
their  hardness;  besides,  they  are  not  now  made  use  of  except  by  some 
of  the  English  practitioners,  and  for  the  construction  of  certain  cup 
pessaries  en  bilboquet ; Haller  published  a case,  which  was  that  of  a 
lady  who  wore  a globe  pessary  made  of  wood,  which  was  employed 
on  account  of  an  incontinence  of  urine  from  paralysis  of  the  vesical 
sphincter.  In  this  case  the  pessary  produced  ulceration  of  the  recto- 
vaginal septum,  so  that,  after  the  extraction  of  the  instrument,  which 
was  got  away  by  means  of  forceps,  her  faeces  escaped  in  part  through 
the  vagina.  ( Collect.  Discuss.  Med.  Chirurg.,  t.  iii.  p.  595,)  De  incon- 
tinentia urince  globulis  ligneis  curandd. 

Wax  and  resin  have  been  abandoned  as  being  too  brittle,  and 
metals  because  they  are  too  hard,  too  heavy,  and  some  of  them  too 
costly;  besides,  they  corrode  and  become  oxydized,  particularly  near 
the  soldering,  which  may  give  rise  to  bad  consequences.  Morand 
( Opuscules  de  Chirurgie , t.  ii.)  informs  us  that  having  introduced  a 
silver  gilt  pessary,  he  was  some  time  afterwards  recalled  to  the  lady 
who  was  suffering  great  inconvenience,  severe  pains  in  the  pelvis 
and  an  excessively  fostid  discharge.  She  attributed  her  distress  to  the 
pessary,  and  when  Morand  removed  it,  he  found  it  corroded,  pierced 
with  several  holes,  and,  moreover,  covered  with  calculous  deposit. 

It  now  remains  for  us  to  speak  of  the  pessaries  most  in  use,  that  is 
to  say,  of  those  that  are  so  erroneously  called  gum-elastic  pessaries, 
for  they  are  really  composed  of  a coat  of  linen,  silk  or  cotton,  and 
sometimes  of  a strong  felt  covered  with  several  layers  of  drying  lin- 
seed oil.  These  are  preferable  to  those  before  mentioned,  although 
they  are  not  free  from  the  objection  of  a liability  to  be  decomposed. 
It  may  also  be  objected  that  they  are  not  very  elastic,  and  that  they 
become  readily  and  frequently  covered  with  a calcareous  deposit, 
which  excites  violent  inflammation  of  the  womb  and  vagina,  ending 
in  ulceration  of  those  parts,  with  very  foetid  discharges. 

Dr.  Rognetta,  in  his  excellent  Memoir  on  Vaginal  Cystocele,  pub- 
lished in  the  Revue  Medicate , 1822,  reports  the  following  case  at  La 
Charit6,  service  of  Professor  Roux.  A country-woman  entered  the 
hospital  to  be  treated  for  a disease,  as  she  supposed,  of  the  womb. 
She  was  examined  by  the  distinguished  surgeon  above  mentioned, 
who  discovered  a foreign  body  in  the  vagina.  The  patient  stated 
that  it  was  a pessary  that  she  had  not  touched  for  many  years.  M. 
Roux  was  obliged  to  make  use  of  strong  forceps  in  the  extraction  of 
the  instrument,  which  gave  her  severe  pain.  After  the  completion  of 
the  operation,  the  pessary,  which  was  as  hard  as  a stone,  and  encrusted 
with  calcareous  matter,  was  found  to  be  of  the  sort  called  gum-elastic, 
and  that  are  most  generally  made  use  of  notwithstanding  their  objec- 
tionable features.  When  upon  the  subject  of  the  accidents  that  may 
follow  the  use  of  the  pessary  in  general,  we  shall  relate  another  case 
in  some  respects  still  more  curious  than  Mr.  Roux’s. 

Finally,  we  come  to  the  consideration  of  the  real  gum  elastic  pes- 
sary, pure  caoutchouc,  in  its  natural  state.  This  material,  by  its  light- 
ness, its  impermeability,  and  its  elasticity,  appears  to  us  to  combine, 


136 


THE  PESSARY. 


in  the  highest  degree,  ail  the  properties  that  are  to  be  desired  in  the 
construction  of  a good  pessary. 

We  are  indebted  to  Madame  Rondet,  sage-femme,  of  Paris,  for  the 
employment  of  caoutchouc  in  the  construction  of  pessaries.  Those  of 
her  manufacture  are  supported  within  by  a very  thin  steel  spring, 
surrounded  with  hair.  We  have  seen  some  of  them,  however,  that 
are  merely  inflated  with  air,  and  have  no  spring  or  hair  within  them. 

Our  friend  and  colleague,  Dr.  Rognetta,  the  author  of  some  import- 
ant remarks  on  different  branches  of  the  science,  and  particularly 
upon  displacements  of  the  genito-urinary  organs  of  the  female,  has 
likewise  prepared  pure  caoutchouc  pessaries,  but  simply  with  gum- 
elastic  bottles,  such  as  are  found  in  the  trade.  The  only  preparation 
that  he  subjects  them  to  consists  in  turning  in  the  top  like  the  bottom 
of  a bottle— then  he  cuts  out  a piece  from  the  centre  of  the  depression 
with  a punch.  It  is  now  a cup  with  double  walls,  and  the  throat  of 
the  bottle,  which  is  like  the  stem  of  the  pessary  en  "bilboquet,  receives 
a metallic  nut  for  the  reception  of  a screw,  to  which  are  attached  three 
braces,  designed  to  keep  the  instrument  in  situ  by  means  of  a belt, 
which  is  itself  supported  by  a pair  of  suspenders.  The  pessary  is  to 
be  removed  every  night,  after  which  the  patient  must  use  cold  water 
injections,  and  be  careful  to  wash  the  instrument  every  morning  before 
she  replaces  it.  M.  Hervez  de  Chegoin,  a distinguished  practitioner, 
and  member  of  the  Academie  de  Medecine,  has  also  made  use  of 
native  caoutchouc  in  the  construction  of  pessaries,  but  he  cuts  the 
bottles  so  as  to  give  to  the  cup  different  degrees  of  depth. 

The  shape  of  the  pessary  varies  according  to  the  material  of  which  it 
is  constructed;  thus  we  have  pessaries  that  are  round,  cylindrical,  oval, 
elytroid,  figure  of  8,  en  bon  c/on,  en  bi/boquet,  crescent-shaped,  ring- 
shaped,  stem  pessaries,  with  springs,  cupped  pessaries,  and  several 
others  that  we  shall  in  succession  review,  at  the  same  time  pointing 
out  the  mode  of  using  them. 

[I  take  advantage  of  the  close  of  this  section  to  make  a few  remarks  on 
the  subject  of  the  pessary,  and  particularly  on  the  pessary  as  psed  in  this 
city ; and,  in  the  first  place,  I must  express  my  conviction  that  great  abuses 
are  to  be  met  with  in  the  prescription  and  use  of  this  instrument,  while  a 
great  many  persons  are  restored  to  health,  and  many  preserve  a tolerable  state 
of  healtli  by  their  use,  who,  but  for  such  aid,  would  become  irremediably 
diseased,  or  pass  a long  life  of  suffering.  Many  objections  have  been  cited 
in  the  preceding  pages  by  our  author  to  the  use,  or  rather  to  the  abuse  of 
this  instrument,  and  the  very  natural  and  perhaps  praiseworthy  opposition 
to  their  employment,  arising  from  considerations  of  a merely  moral  nature, 
ought  to  be  encouraged  as  a means  of  preventing  their  unnecessary  use  as 
means  of  treatment  in  cases  not  at  all  calculated  to  be  benefited  by  them. 
It  seems  to  me  that,  in  view  of  the  nature  of  the  support  by  means  of  which 
the  womb  retains  its  natural  situation  in  the  pelvis,  every  case  of  prolapsion 
or  procidentia  of  the  womb  ought  to  be  regarded  as  an  affection  of  the 
vagina,  and  that  the  indication  of  cure  confines  itself  to  the  restoration  of  the 
vagina  and  not  of  the  womb  as  the  pathological  object. 


THE  PESSARY. 


137 


The  abdominal  cavity  is  terminated  above  by  the  cohcave  of  the  dia- 
phragm, and  inferiorly  by  the  floor  of  the  pelvis,  consisting  of  tissues  of  com- 
bined muscles,  fasciae,  cellular  tela  and  skin.  In  the  act  of  parturition,  and  in 
that  of  defecation,  the  inferior  portion  of  the  abdominal  cavity  is  depressed  by 
the  action  of  the  diaphragm  and  abdominal  muscles,  which  press  the  mova- 
ble contents  towards  the  outlet,  and  depress  it.  In  this  act  the  whole  peri- 
neum descends  more  or  less  considerably,  and  after  the  completion  of  the 
act  returns  to  its  natural  position,  partly  by  means  of  its  contractility  of  tex- 
ture, and  partly  by  the  act  of  the  levator-ani  muscles — muscles  that  in  almost 
every  instance  of  this  return  are  put  into  voluntary  activity. 

With  the  progress  of  age,  and  under  the  debilitating  powers  of  disease,  the 
perineal  terminus  of  the  abdominal  cavity  grows  less  and  less  able  to  resist 
the  antagonization  of  the  diaphragm  and  abdominal  muscles ; so  that,  in 
such  circumstances,  the  perineum  becomes  relaxed,  and  is  found  to  be 
nearly  horizontal  or  quite  even  with  the  tubera  ischii ; whereas,  in  young 
and  healthy  persons  it  is  drawn  upwards  so  as  to  make  a deep  sulcus  above 
the  level  of  those  tuberosities. 

In  all  persons  possessed  of  very  powerful  levators-ani,  the  extremity  of 
the  rectum  will  be  highly  retracted  within  the  pelvis,  and  retained  there  by 
the  steady  and  normal  tension  of  those  muscles — but  in  those  in  whom  those 
levators  are  thin  and  weak,  the  anus  is  found  lower  and  on  a level  with  the 
tubera,  or  even  projecting  below  them.  This  case  may  sometimes  be 
detected  in  young  children  exhausted  with  the  long  tenesmus  of  summer 
complaint;  in  adults,  under  protracted  diarrhoea,  dysentery,  and  other  enfee- 
bling maladies,  as  well  as  in  women  whose  constitutions  are  broken  up  by 
frequent  parturition. 

Now  let  it  be  remembered  that  the  levator  ani  is  a levator  vaginae,  and,  in 
the  same  sense,  a levator  uteri,  and  that  in  all  persons  in  whom  these  mus- 
cles have  become  extenuated  and  weak,  there  will  be  a greater  or  less  dispo- 
sition to,  or  actual  falling  of  the  womb ; and  that  such  a condition  is  incom- 
patible with  comfortable  sensations  in  the  muscles  in  question.  Even  the 
constrictor  vaginae  muscle  is,  to  a certain  degree,  a part  of  the  muscular 
material  in  question,  since  the  levators  and  sphincters,  both  of  the  anus  and 
vagina,  have  their  fibres  more  or  less  blended,  and  there  is  a consent  in 
their  actions.  The  levators  relax  coincidently  with  the  relaxation  of  the 
sphincter  ani,  and  their  contractile  efforts  absolutely  coincide. 

Seeing  now  that  the  uterus  depends  for  its  place  in  the  plane  of  the  pelvic 
cavity,  solely  upon  the  place  of  the  vagina,  and  that  the  latter  is  indissolubly 
connected  with  the  bowel  by  means  of  the  recto-vaginal  septum,  it  appears 
clearly  that  all  cases  of  prolapsion  have  also  a clear  connection  with  a certain 
morbid  condition  of  the  levator  muscles.  The  same  thing  happens  in  the 
case  of  falling  of  the  palate  or  uvula,  which  is  clearly  a muscular  weak- 
ness, arising  from  an  inflammation,  either  acute  or  chronic,  of  the  substance 
of  the  palate  or  uvula. 


138 


THE  PESSARY. 


\ 


It  hence  appears,  that  in  cases  of  prolapsus  uteri,  I suppose  that  one 
great  object  to  be  held  in  view  is  the  restoration  to  the  levators  of  their  lost 
or  diminished  contractility. 

Doubtless,  cases  of  prolapsion  are  most  to  be  feared  after  long,  tedious,  or 
instrumental  labours — labours  where,  from  rigidity  or  bad  proportion,  the 
child  has  remained  many  hours  within  the  pelvic  cavity,  jamming  the  mus- 
cular and  other  tissues  within  against  the  sides  of  the  ischia,  whose  bony 
walls  on  the  one  hand  contuse  these  muscles,  while  the  head  on  the  other  is 
equally  capable  of  affecting  them  with  contusion. 

After  such  a labour,  a woman  is  very  apt  to  get  up  from  her  lying-in  with 
weakened  levators,  with  the  rectum  feebly  supported,  and  the  uterus  con- 
sequently lower  than  it  ought  to  be ; in  fact,  very  few  women  are  to  be  met 
with  in  whom,  after  giving  birth  to  one  or  two  children,  the  womb  is  not 
found  very  low  in  the  pelvis.  If  she  early  becomes  a widow,  or  at  an  early 
age  ceases  to  bear  children,  the  tension  of  these  tissues  is  at  length  restored 
to  the  womb,  and  the  whole  perineum,  indeed,  rises  again,  until  the  approach 
of  age  is  evinced  by  the  last  and  permanent  fall  of  the  perineum  with  all 
the  contents  of  the  pelvis. 

Under  this  view,  how  necessary  does  it  seem  that  such  patients  should 
avoid  all  the  causes  of  tenesmus,  such  as  costiveness  on  the  one  hand,  and 
drastic  or  other  harsh  cathartics  on  the  other,  pessaries  of  a bad  construction, 
of  too  large  a size,  strangury,  debilitating  discharges  of  leucorrhcea,  and, 
in  short,  whatever  might  serve  to  promote  the  descent  of  the  perineal  texture, 
the  descent  of  which  is  incompatible  with  a due  elevation  of  the  organs 
whose  support  in  situ  naturali  absolutely  depends  upon  them. 

I beg  leave  to  remark  that,  in  pursuance  of  a plan  of  treatment  by  rest  in 
a horizontal  posture  very  long  continued,  the  muscular  force  of  tfie  patient 
is  not  unapt  to  be  exhausted,  and  that  it  is  not  unusual  for  persons  subjected 
to  such  treatment,  to  rise  from  a confinement  to  the  bed  of  several  months, 
duration,  not  at  all  amended  in  health,  and  consequently,  greatly  disappointed, 
if  not  injured  by  the  treatment.  In  such  patients,  a method  calculated  to 
invigorate  and  enhance  the  muscular  energies  would  be  far  more  likely  to 
produce  a cure  which  would  coincide  with  a rise  or  elevation  of  the  perineum. 
Hence,  I have,  in  many  instances,  found  my  patients  to  recover  perfectly, 
when  I have  counselled  them  to  take  exercise,  to  be  much  in  the  air  and  light, 
to  live  upon  a nutritious  diet,  to  take  wine  and  malt  liquor,  and  to  disregard, 
as  far  as  possible,  the  painful  or  annoying  sensations  proceeding  from  the  pro- 
lapsed state  of  the  womb;  assuring  them  that,  probably,  in  proportion  as  their 
general  health  should  improve,  so  would  the  local  disorders,  under  which  she 
suffered,  gradually  lessen  and  finally  disappear.  I have  seen  a lady  this  day, 
who,  at  the  age  of  forty-nine  years,  informs  me  that  she  has  scarcely  been  a 
day  or  night  without  a pessary  for  fourteen  years  past,  an  instrument  for 
which  6he  has  not  the  least  occasion,  and  perhaps  never  has  had. 

In  making  these  remarks,  I desire  to  apply  them  to  cases  where  the  use 


USE  OF  THE  PESSARY. 


139 


of  the  pessary  is  a question  of  doubt,  for,  beyond  dispute,  there  are  many 
women  who  can  enjoy  neither  comfort  nor  health  without  the  aid  of  these 
remedies,  which,  as  our  author  states,  are  sanctioned  by  the  common  con- 
sent of  the  profession  for  ages  past. — M.] 

OF  THE  PRINCIPAL  PESSARIES  IN  USE,  AND  THE  METHOD  OF  EM- 

PLOYING  THEM. 

Whatsoever  may  be  the  nature  or  form  of  the  pessary  selected  for 
the  purpose  of  keeping  the  womb  in  place  after  it  has  been  reduced 
from  its  prolapsion,  its  application  should  be  rendered,  generally, 
subject  to  the  following  rules  : 

After  having  emptied  the  rectum  by  means  of  an  enema,  and 
directed  the  patient  to  evacuate  the  urine,  she  should  place  herself 
upon  the  back,  with  the  hips  raised  upon  a cushion,  the  knees  sepa- 
rated, the  legs  somewhat  flexed,  and  the  feet  resting  firmly  upon  the 
bed.  The  pessary,  anointed  with  cerate  or  oil,  is  then  introduced 
by  the  surgeon  into  the  vagina,  taking  care  to  present  it  in  such  a 
way  that  its  smallest  diameter  shall  be  coincident  with  the  smallest 
diameter  of  the  orifice,  and  pressing  it  as  much  as  practicable  towards 
the  inferior  commissure  of  the  labia,  then  pushing  the  instrument 
carefully  from  before  backwards  and  upwards,  he  will  carry  it  up  to 
the  height  at  which  he  designs  that  it  shall  remain,  when  he  gives 
it  the  position  he  may  deem  requisite,  seeing  that  the  os  tincse  may 
always  correspond  to  the  central  opening. 

[In  the  globe  pessary  constructed  here,  and  much  in  use  in  this  country, 
there  is  no  central  opening,  and  as  the  instrument  is  a sphere,  it  requires  no 
farther  care  than  to  place  it  in  the  vagina  beyond  the  constrictor  muscle.  I 
shall  speak  of  this  pessary  in  another  page. — M.] 

In  order  that  the  neck  of  the  womb  may  the  more  perfectly  adapt 
itself  to  the  concavity  of  the  pessary,  the  operator,  supporting  the 
instrument  with  the  index  finger,  should  allow  the  patient  to  rise  and 
sit  up  for  a moment,  and  even  to  walk  a few  steps,  and  to  cough,  in 
order  to  learn  whether  the  instrument  maintains  its  place,  and  pro- 
duces no  painful  sensation,  which,  being  found  to  be  the  case,  he 
should  allow  her  to  return  to  her  bed,  whence  she  ought  not  to  rise 
for  a few  days.  After  getting  up  from  her  bed,  she  would  do  well 
to  pass  a few  days  upon  a couch  or  sofa,  and,  as  far  as  possible,  avoid 
any  sudden  movement. 

Round  pessaries  and  pessaries  h cuvettes  are  flattened  on  the  face, 
and  exhibit  a central  depression  of  considerable  depth,  with  a central 
perforation  that  ought  to  correspond  with  the  os  tincae.  The  pessary 
a cuvette  differs  from  the  round  pessary,  properly  so  called,  only  in 
being  concavo-convex.  These  two  sorts  of  pessaries,  that  for  a long 
time  have  been  made  of  cork,  covered  with  a coating  of  wax,  or  of 
box-wood,  are  at  the  present  day  generally  made  with  gum-elastic. 
In  introducing  them,  they  are  pushed  edgewise  into  the  vagina,  and 
afterwards  turned  so  as  to  make  the  central  orifice  correspond  to  the 
os  uteri.  This  may  be  done  by  introducing  the  tip  of  the  finger  into 


140 


USE  OP  THE  PESSARY. 


the  opening  of  the  instrument,  or,  previously  to  introducing  it,  a rib- 
bon may  be  fastened,  by  means  of  a knot,  to  the  smallest  end  of  the 
pessary,  and  when  the  time  arrives  for  turning  the  instrument,  it  may 
be  pulled  downwards  by  the  ribbon  while  the  piece  is  supported  by 
one  or  two  fingers,  introduced  for  the  purpose,  and  pressed  against 
the  opposite  extremity  or  side. 

This  little  ribbon  should  be  left  in  the  vagina,  for  the  purpose  of 
more  readily  extracting  the  pessary  whenever  it  may  be  necessary  to 
cleanse  it  or  replace  it  by  another  one,  or  when  the  parts  of  genera- 
tion may  require  to  be  cleansed ; should  the  ribbon,  however,  be  found 
to  irritate  or  give  any  trouble,  it  should  be  cut  off*  and  taken  away. 

The  oval  pessary,  which  differs  from  the  round  one  only  in  its 
shape,  is  objectionable,  because  it  is  easily  displaced,  and  because  it 
distends  the  upper  part  of  the  vagina  too  much,  in  a transverse  di- 
rection, which,  in  some  cases,  is  very  painful  or  even  insupportable. 
It  is  introduced  lengthways,  being  slightly  inclined  to  the  left,  in 
order  to  avoid  compressing  the  urethra.  After  it  has  passed  quite 
into  the  canal,  it  is  turned  so  as  to  assume  a horizontal  position, 
by  means  of  a loop  attached  to  the  end  that  is  first  introduced,  the 
loop  being  pulled  downwards  by  one  hand,  while  the  other  supports 
the  opposite  extremity  of  the  oval  pessary. 

Ovoid  pessaries  are  nearly  of  the  size  and  shape  of  a small  turkey’s 
egg,  and  are  traversed  by  a cylindrical  hole  from  end  to  end.  These 
pessaries,  which  are  employed  only  by  the  English  and  American 
surgeons,  are  inconvenient  on  account  of  the  facility  with  which  they 
are  displaced  under  the  least  effort  of  the  patient.  Yet  the  introduc- 
tion of  this  sort  is  very  easy. 

[M.  Colombat  is  under  some  misapprehension  in  regard  to  the  use  of  the 
egg-shaped  pessary  by  the  American  surgeons.  In  fact,  the  egg-shaped 
instrument  is  rarely  employed,  so  far  as  I know.  In  order  to  set  the  matter 
forth  in  its  proper  light,  I shall  proceed  to  cite,  in  this  place,  some  paragraphs 
from  the  Philad.  Pract.  of  Midwifery,  by  the  translator,  p.  145.  “ Pessaries 
are  made  of  various  shapes,  and  of  a great  variety  of  materials.  Many  are 
made  of  a piece  of  cork,  cut  into  a proper  form,  and  repeatedly  dipped  in 
melted  wax  until  covered  with  a thick  coat  of  that  substance.  The  objec- 
tion to  this  kind  is,  that  by  the  warmth  of  the  organs  the  wax  becomes  so 
much  softened  that  the  rough  surface  of  the  cork  sometimes  becomes  un- 
covered, and  then  irritates  the  parts  with  which  it  is  in  contact.  Others  are 
made  of  the  same  material  that  is  used  for  the  construction  of  elastic  cathe- 
ters and  bougies.  Others,  again,  are  made  of  glass,  blown  by  the  glass- 
blower  into  a convenient  size  and  form.  Some  are  used  that  consist  of 
silver,  and  some  are  of  silver  washed  with  gold.  Of  the  metallic  pessaries 
now  principally  in  use,  in  our  American  practice,  two  kinds  are  prepared; 
one  of  which  is  the  flat  pessary,  or  rather  the  disc-like  pessary,  which  is 
concavo-convex,  with  a very  thick  periphery,  and  having  a small  perforation 
in  the  centre  of  its  concavity.  The  other  is  a globe  of  silver  washed  with 
gold  so  as  to  prevent  the  oxidation  of  the  surface.  Both  of  these  pessaries 
are  made  of  plates  of  metal  so  thin  that  they  are  sufficiently  light;  and  as 


USE  OF  THE  PESSARY. 


141 


the  gilded  surface  admits  of  a high  polish,  they  are  as  little  likely  to  irritate 
the  parts  they  touch  as  any  foreign  body  that  could  be  constructed.  1 much 
prefer  the  metallic  to  the  glass  pessary,  on  account  of  the  greater  lightness 
of  the  former.  It  appears  to  me,  that  a globular  pessary  is  capable  of  ful- 
filling all  the  indications  that  could  possibly  be  collected  for  a mechanical 
remedy  for  this  affection  (prolapsus  uteri).  I prefer  it  in  general,  therefore, 
to  all  other  forms  of  the  instrument,  particularly  since  it  cannot  become  dis- 
placed by  turning  on  its  axis;  a fault  frequently  found  with  the  flat  or  discoidal 
instrument.  I am  fully  confirmed  in  my  appreciation  of  its  superior  value. 
The  globe  pessary  was,  I believe,  the  only  instrument  used  by  the  late  Dr. 
Physick,  in  the  treatment  of  prolapsus  uteri.  He  told  me  that  while  he 
was  a pupil  of  Mr.  John  Hunter,  and  acting  as  dresser  at  Guy’s  Hospital, 
he  had  under  his  care  the  case  of  a patient  who  had  suffered  severely  with 
prolapsus  uteri.  One  day,  while  paying  his  visits,  he  saw  a billiard  ball 
that  had  been  rolling  about  the  ward,  and  the  idea  struck  him  that  it  might 
serve  to  support  the  womb  in  the  case  in  question.  He  introduced  it,  and  it 
succeeded  so  perfectly  in  alleviating  her  distress,  that  he  ever  afterwards  pre- 
ferred to  employ  the  globe  rather  than  the  disc  or  any  other  of  the  numerous 
forms  of  the  instrument.” 

I take  this  occasion  to  say  that  both  the  discoidal  and  globe  pessary  are 
made  by  Mr.  Jos.  S.  Warner,  Merchant  street,  Philadelphia,  »nd  that  they 
are  sold  at  the  rate  of  five  dollars  each,  which  renders  them  rather  too  costly 
for  common  use ; yet  it  is  proper  to  say,  that  the  construction  is  so  perfect 
that  they  often  remain  one,  two,  or  even  three  years  in  situ,  without  under- 
going oxidation  or  losing  their  polish.  The  plates  of  hammer-hardened 
silver  of  which  they  are  made,  are  so  thin,  that  the  weight  of  the  instrument 
is  very  inconsiderable  ; many  grains  of  pure  gold  are  put  on  the  surface, 
which  preserves  them  from  oxidation  for  a long  time,  as  above  mentioned. 

For  the  most  part,  a globe  pessary,  of  two  inches  and  a quarter  in  diame- 
ter, is  both  small  enough  and  large  enough.  Occasionally  persons  are  met 
with,  to  whom  the  introduction  of  one  of  more  than  two  inches  gives  con- 
siderable pain;  and  others,  again,  in  whom  the  os  magnum  is  so  relaxed  and 
debilitated  that  two  and  a half  inches  are  barely  large  enough  for  a pessary 
suited  to  the  case. 

In  adjusting  this  instrument,  the  general  rule  laid  down  by  our  author 
ought  to  be  observed.  I mean  that  relative  to  the  evacuation  of  the  bladder  and 
the  rectum  ; after  which  the  patient  should  get  into  bed,  lying  upon  her  left 
side,  with  her  thighs  at  right  angles  to  the  trunk,  and  the  knees  flexed,  with 
a pillow  between  them.  If  the  globe  be  now  dipped  in  olive  oil,  and  pressed 
against  the  os  magnum  with  a gentle  force,  which  should  be  intermitted  or 
suspended  from  time  to  time,  in  simulation  of  the  dilating  processes  of  a 
labour  or  abortion,  it  will,  in  general,  be  found  not  difficult  to  adjust  the 
instrument.  It  is  very  much  to  be  desired  that  a good  deal  of  time  should 
be  required  to  place  it  within  the  vagina,  for  if  it  enters  too  readily,  or  with 


142 


USE  OF  THE  PESSARY. 


too  little  force,  it  will  be  surely  expelled  at  the  first  bearing  down  in  defe- 
cation, or  even  in  evacuating  the  bladder  of  urine  ; whereas,  if  it  require 
time  and  some  resolute  application  of  force  to  adjust  it,  it  will  be  very  little 
likely  to  give  trouble  and  vexation  by  an  escape.  To  every  woman  who 
has  recently  suffered  the  introduction  of  such  an  instrument,  the  advice 
ought  to  be  given  never  to  go  out  without  the  napkin,  lest,  in  some  sudden 
fit  of  cough  or  sneezing  or  laughter,  the  ball  might  be  driven  from  its  place, 
to  her  mortification  and  dismay. 

The  globe  requires  no  cuvette  or  depression,  because,  when  adjusted,  the 
anterior  face  of  the  cervix  uteri  lies  upon  the  upper 
Fig*  17.  and  posterior  segment  of  the  ball,  the  os  tincae 


looking  backwards  and  downwards  towards  the 
sacrum,  as  in  the  figure,  which  shows  very  well 
that  the  womb  must,  under  the  use  of  such  an  in- 
strument, be  very  much  elevated  in  the  excavation 
of  the  pelvis.  I may  add  that  every  contractile 
effort  of  the  sphincter  vaginae,  and  more  particularly, 
every  contraction  of  the  levator  ani  muscles  must 
push  the  globe  upwards,  carrying  the  womb  upwards 
along  with  it. — M.] 


The  ring  pessary,  or  pessary  en.  gimblette , is  wide,  thick,  with 
rounded  edges,  and  with  a central  perforation,  beveled  upon  both 
surfaces,  but  most  upon  that  which  is  in  contact  with  the  os  uteri. 
These  pessaries,  which  are  characterized  by  several  inconveniences, 
that  we  shall  hereafter  refer  to,  may  be  introduced  edgeways,  and 
agreeably  to  the  rules  before  laid  down,  as  relative  to  the  round 
pessary. 

The  figure  of  8 pessary,  invented  by  Brunninghausen,  is  notched 
both  on  its  anterior  and  posterior  edge,  for  the  purpose  of  avoiding 
any  interference  with  the  rectum  or  the  bladder ; but  it  is  inconve- 
nient, and  much  more  easily  displaced  than  the  ring  pessary,  which 
dilates  the  vagina  equably,  and  forms  a sort  of  circular  sulcus,  that 
prevents  it  from  getting  out  of  place.  It  is  introduced  in  the  same 
manner,  and  according  to  the  same  rules  as  are  applied  for  the  oval 
pessaries. 

The  stern-pessary , or  pessary  en  bilboquet,  the  employment  of 
which  seems  chiefly  indicated  after  the  reduction  of  a complete  pre- 
cipitation of  the  womb,  is  commonly  fabricated  of  box  or  ivory,  or 
what  is  still  better,  of  caoutchouc.  At  the  uterine  extremity,  these 
instruments  exhibit  a concavity,  the  thick,  rounded  edge  of  which 
resembles  that  of  a pessary  en  gimblette , and  the  bottom  of  which 
has  three  larse  openings.  To  the  convex  surface  of  the  cup  is  fixed, 
by  means  of  three  branches,  a straight  stem  or  rod,  which  is  open  at 
its  vulvar  end,  so  as  to  admit  of  the  ribbons,  by  means  of  which  it  is 
secured  to  the  girdle  or  T bandage,  which  the  patient  ought  always 
to  wear. 

The  pessary  en  bilboquet , invented  during  the  last  century,  by 


USE  OF  THE  PESSARY. 


143 


Suret,  a surgeon,  has  undergone  various  modifications  in  the  hands 
of  different  surgeons,  as  F.  Beaulieu,  Saviard,  Preuner,  Bauhin, 
Zeller,  Desormeaux,  Recamier,  Villerme,  Guillon,  Deleau,  &c.  Beau- 
lieus’s  instrument  consists  of  a silver  circle  supported  by  a sort  of 
three-pronged  fork.  Saviard’s,  made  of  steel,  consists  of  a spring,  one 
extremity  of  which  is  surmounted  by  a small  spring,  which  assumes 
a curve  in  the  vagina,  while  the  free  end  is  attached  to  the  girdle. 
Professor  Boyer  made  use  of  a spring  of  this  sort,  which  was  sur- 
mounted by  a sponge  for  the  purpose  of  keeping  the  prolapsed  womb 
in  its  proper  situation ; and  he  used  it  particularly  in  cases  in  which 
too  much  irritation  and  pain  were  produced  by  the  ordinary  sorts  of 
pessaries. 

In  order  to  render  the  stem  more  elastic  in  its  longitudinal  direc- 
tion, M.  Recamier  conceived  the  idea  of  composing  it  of  a spring 
en  boudin , (suspender  spring,)  probably  covered.  Professor  Duges 
thought  the  stem  ought  to  be  placed  obliquely  as  to  the  cup,  as  the 
vagina  is  in  regard  to  the  axis  of  the  cervix  uteri. 

Bauhin’s  pessary  was  composed  of  a rather  small  silver  circle, 
forming  a sort,  of  thick  cushion,  sustained  on  a three-branched  stem, 
and  pierced  with  a hole  in  the  centre.  Villerme’s,  founded  on  the  same 
principle  as  that  of  Saviard,  consists  in  a long  arch,  the  concavity  of 
which  embraces  the  front  of  the  pelvis.  The  tail  of  the  piece,  which 
is  a sort  of  crotchet,  rests  upon  the  hypogastrium,  while  the  head  of 
the  instrument,  introduced  within  the  vagina,  serves  to  support  or 
suspend  the  womb  in  its  proper  place.  Our  colleague,  Dr.  Deleau, 
to  whom  the  science  is  indebted  for  important  improvements,  has 
also  constructed  a pessary  which  unites  the  qualities  of  the  pessary 
en  bilboquel  and  the  pessary  en  gimblette.  This  ingenious  instru- 
ment is  constructed  as  a spiral  spring,  the  first  circle  at  the  top  of 
which  is  fixed. , while  that  which  is  at  the  base  is  free,  and  may  be 
made  larger  or  smaller  at  will.  The  whole  is  coated  with  caout- 
chouc. When  it  is  to  be  used,  the  circle  at  the  base  is  more  or  less 
reduced,  and  being  introduced  into  the  vagina  with  the  smallest  end 
upwards,  it  is  left  there,  and  accommodates  itself  to  the  dimensions 
of  the  organ,  without  any  liability  to  displacement.  Dr.  Guillon  has 
also  modified  the  stem-pessary  by  combining  the  bilboquet  and  the 
cork  one  by  means  of  a hollow  stem,  which  is  a screw,  by  turning 
which  the  uterus  is  elevated  at  will. 

In  adjusting  a stem-pessary,  the  cupule  end  must  be  introduced 
into  the  vagina  gradually,  giving  to  the  stem  its  proper  direction. 
When  it  has  passed  far  enough,  it  is  to  be  secured  by  the  T bandage, 
as  already  mentioned. 

We  shall  presently  explain  the  inconveniences  connected  with  the 
stem-pessary,  which,  as  they  rarely  remain  in  the  centre  of  the 
vagina,  are  found  to  see-saw  within  the  passage,  which  they  contuse, 
and  sometimes  even  perforate  with  the  end  of  the  stem.  Dr.  Laroche 
extracted  one  of  this  sort,  which  had  fixed  itself  transversely,  so  that 
the  stem  had  penetrated  the  bladder,  while  the  cupule  had  pierced 
the  rectum.  The  cupule  had  become  the  nucleus  of  a stercoral 
concretion,  composed  of  large  crystals  that  adhered  to  it,  while  the 


144 


USE  OF  THE  PESSARY. 


stem  itself,  in  the  cavity  of  the  bladder,  had  covered  itself  with  a 
calculous  concretion  of  uric  acid. 

The  pessary  en  bonclon,  or  conoidal  pessary,  is  commonly  made 
of  caoutchouc,  and  generally  in  the  form  of  a long,  hollow  cone, 
truncated  at  top,  which  is  cup-shaped,  with  a central  cavity  for  the 
reception  of  the  neck  of  the  womb,  the  other  extremity  being  sup- 
ported by  strings  attached  to  the  girdle.  These  pessaries,  which  are 
chiefly  used  in  cases  where  the  vagina  remains  prolapsed,  notwith- 
standing the  reduction  of  the  uterus  itself,  are  inserted  with  the  large 
end  first,  which  must  be  compressed  in  the  fingers  of  the  operator, 
to  make  it  enter  the  vagina.  It  is  inconvenient,  as  being  too  heavy, 
and  as  tending,  by  the  sharpness  of  its  edges,  to  contuse  and  injure 
the  parts. 

Professor  J ules  Cloquet  is  the  author  of  an  instrument  called  the 
elytroid  pessary,  of  a shape  calculated  to  conform  as  closely  as  pos- 
sible to  that  of  the  vagina  itself.  These  instruments  are  constructed 
of  a web,  covered  with  varnish  or  caoutchouc.  They  are  hollow, 
flattened  antero-posteriorly  so  as  to  present  a convex  face  towards 
the  rectum,  and  a concave  one  towards  the  bladder.  At  the  upper 
end  is  a transverse  oval  depression  or  cupule.  A tubular  canal  leads 
from  top  to  bottom  of  the  instrument,  for  the  purpose  of  a conduit  to 
the  mucous  and  menstrual  excretions.  The  lower  end  has  a rounded 
angle  at  each  side,  which  rests  within  the  vagina,  above  the  vulva. 
These  pessaries,  which,  to  a certain  extent,  mould  themselves  to  the 
form  of  the  vagina,  certainly  do  support  the  womb  and  its  append- 
ages perfectly  well ; but,  in  consequence  of  their  weight,  they  are 
found  to  be  fatiguing  to  the  women  who  use  them.  They  are  at- 
tended with  another  inconvenience,  common,  indeed,  to  all  tubular 
pessaries,  which  is,  that  they  impede  the  discharge  of  the  menses ; 
lor  the  blood  often  coagulates  within  and  obstructs  the  tube.  M. 
Cloquet’s  elytroid  pessary  is  closely  analogous  to  that  which  is 
figured  by  Smellie,  in  the  XXXVIII  Plate  of  his  Treatise  on  Mid- 
wifery. 

In  introducing  the  elytroid  pessary,  its  inventor,  M.  Cloquet,  directs 
that  the  cupped  end  should  be  presented  to  the  orifice,  but  directed 
so  that  the  convex  surface  of  the  elytra  should  look  towards  the 
patient’s  left  thigh.  The  instrument  is  now  to  be  slowly  pressed 
upwards,  and,  when  the  lower  end  has  passed  the  vulva,  the  right 
index  ought  to  be  placed  within  the  hollow  of  the  instrument,  and, 
with  the  left  index,  it  should  be  adjusted  so  that  its  concavity  may 
be  placed  in  correspondence  with  the  bladder,  and  its  convexity 
made  1o  look  towards  the  rectum. 

Finally,  Dr.  Brouard  has  recently  invented  a pessary  with  lateral 
and  divergent  stems,  composed, 

1st.  Of  an  ivory  or  ebony  ring,  eighteen  to  twenty  lines  in  dia- 
meter. 

2d.  Of  two  branches  of  silver  or  other  metal,  twenty-one  lines  in 
width.  These  branches  are  attached  to  the  under  surface  of  the 
ring,  and  terminate  in  two  ivory  buttons.  According  to  its  inventor, 
this  pessary,  which  is  easy,  both  as  to  its  introduction  and  re- 


CHOICE  OF  THE  PESSARY. 


145 


moval,  differs  from  all  former  ones  in  size,  in  its  point  d’appui  and 
its  operation.  In  fact,  the  smallness  of  the  ring  renders  its  introduc- 
tion very  easy,  and  much  less  painful  than  that  of  the  other  sorts. 
The  point  d’appui  is  not  taken  in  the  ratio  of  the  circumference  of 
the  ring,  but  it  depends  on  the  divergence  of  the  elastic  branches,  the 
buttons  of  which  rest  upon  the  inferior  lateral  portions  of  the  vagina. 

Should  this  instrument  be  found  to  possess  all  the  advantages 
claimed  for  it  by  the  inventor,  we  have  no  doubt  of  its  coming  into 
general  use  ; particularly  as  a support  in  cases  of  procidentia  of  the 
womb  ; but  it  never  can  take  precedence  of  the  cylindrical  forms  of 
the  pessary,  in  cases  connected  with  the  various  vaginal  hernias. 


OF  THE  CHOICE  OF  A PESSARY. 

According  to  most  authors,  the  round  pessary  is  indicated  where 
the  diameter  of  the  vagina  is  small ; but,  under  contrary  circum- 
stances, choice  is  generally  made  of  an  oval,  or  gimblette,  or  figure 
of  eight  pessary. 

The  stem  or  bilboquet  pessary  is  chiefly  used  where  the  axes  of 
the  superior  strait  are  very  large,  and  the  woman  emaciated;  or 
where  the  walls  of  the  vagina,  on  account  of  their  weakness  and 
flaccidity,  could  not  readily  retain  the  instrument  that  is  placed  within 
them  for  supporting  the  womb. 

The  pessary  ci  bondon  is  reserved  for  cases  in  which  the  vagina  is 
still  prolapsed,  notwithstanding  the  uterus  itself  is  reduced.  The 
elytroid  pessaries,  which,  in  many  cases,  supersede  the  others,  are 
perhaps  better  suited  than  any  others  for  the  cases  of  anteversion  and 
retroversion  of  the  womb ; in  which  we  must  raise  that  end  highest 
that  is  designed  to  keep  the  womb  in  situ, — of  the  particular  devia- 
tions of  which  we  shall  hereafter  treat.  The  cylindrical  gum-elastic 
pessary  of  Dr.  Rognetta  fulfils  the  same  indications  perfectly  well, 
and  is  especially  excellent  as  a remedy  for  vaginal  enterocele  and 
cystocele. 

Where  the  patient  has  been  troubled  with  a very  copious  uterine  or 
vaginal  catarrh,  the  use  of  the  pessary  ought  to  be  deferred  until  this 
particular  malady  shall  have  been  removed  or  at  least  much  amended ; 
for  the  presence  within  the  vagina  of  such  instruments  could  only 
increase  the  evil.  In  doing  this  we  should  but  follow  out  the  prin- 
ciple laid  down  by  Boyer  in  his  Treatise  upon  Surgical  Diseases , 
tom.  x.,  where  he  says  that  the  pessary  should  never  be  employed 
except  in  cases  where  the  os  uteri  is  neither  engorged  nor  painful, 
and  where  we  are  certain  that  the  symptoms  experienced  by  the 
patient  are  dependent  upon  displacement  of  the  womb,  and  not  upon 
engorgement  or  elongation  of  its  neck. 

ACCIDENTS  CONNECTED  WITH  THE  PRESENCE  OF  A PESSARY  IN 

THE  VAGINA. 

Pessaries  of  all  kinds  never  fail  to  excite  more  or  less  irritation. 
The  almost  inevitable  pressure  of  the  instrument  upon  the  parts  con- 

10 


146 


INCONVENIENCES  OF  THE  PESSARY. 


rained  within  the  pelvic  cavity  impedes  the  functions  of  the  organs, 
more  especially  those  of  defecation  and  urination.  It  often  happens 
that  the  uneasiness  and  the  insupportable  pains  which  they  produce 
extend  to  the  loins  and  the  groins,  and  give  rise  to  engorgement  of  the 
inferior  extremities. 

Women  who  make  use  of  the  pessary  without  great  attention  to 
means  of  cleanliness,  are  often  attacked  with  pernicious  symptoms ; 
for  by  being  left  too  long  in  situ,  the  instrument  undergoes  decom- 
position, corrodes,  and  is  coated  with  calcareous  incrustation;*  be- 
coming in  this  way  the  cause  of  permanent  irritation,  it  excites  in- 
flammation and  change  of  texture,  ending  in  the  formation  of  purulent 
vegetations  that  exhale  the  most  repulsive  odour : the  action  of  the 
mucous  apparatus  being  increased,  acquires  an  exaggerated  vitality 
that  gives  rise  to  vegetations  that  become  so  abundant  as  not  only 
to  fill  the  vagina,  but  to  cover  up  the  whole  pessary  and  com- 
pletely conceal  it  from  the  touch.  Desormeaux,  the  father  of  the 
professor  whose  recent  loss  we  deplore,  was  obliged  to  excise  a 
great  number  of  vegetations  before  he  could  succeed  in  extracting 
a pessary  that  had  perforated  both  the  bladder  and  the  rectum. 
Professor  J.  Cloquet,  in  consultation  in  the  case  of  a lady  under  treat- 
ment for  cancer  of  the  vagina,  found  the  canal  filled  with  fungous 
vegetations:  having  decided  to  remove  these  fungous  masses,  he 
discovered  a pessary  within  the  vagina  and  extracted  it.  The  instru- 
ment which  had  been  forgotten  for  ten  years,  was  completely  covered 
with  fungous  matter  and  coated  with  a calcareous  incrustation.  Acad, 
de  Med.,  29  June,  1326. 

Whenever  the  central  opening  of  a pessary,  particularly  a round 
one,  an  oval  one,  a cupped  one,  or  one  with  a ring,  is  too  large,  the 
neck  of  the  womb  is  liable  to  become  slowly  engaged  within  the 
opening,  and  at  length  strangulated,  and  after  a time  gives  rise  to  the 
most  serious  consequences — such  cases  have  been  seen. 

The  Annals  of  Medicine  of  Ollemburg  for  Oct.,  1826,  and  the  Bib - 
Uotheque  Medicate,  t 17,  p.  269,  mention  a young  unmarried  Dutch 
girl  who,  being  affected  with  prolapsus,  made  use  of  a ring  pessary 
of  ivory,  the  opening  of  which  being  too  large,  produced  a strangula- 
tion of  the  womb,  exhibiting  a tumour  external  to  the  organs  nearly 
as  large  as  a child’s  head.  As  the  patient  was  in  the  utmost  pain, 

* On  the  25th  March,  1832, 1 was  requested  to  see  the  Baroness  de  Carl  . . . who  was 
then  about  75  years  of  age,  and  who  in  common  with  her  whole  family  supposed  herself 
to  be  afflicted  with  cancer  of  the  womb.  What  seemed  in  fact  to  justify  this  distressing 
diagnosis  was  that  Madame  de  Carl  . . . was  affected  with  intolerable  pain  and  a most 
profuse  and  foetid  vaginal  discharge.  Instead  of  finding  a cancerous  tumour,  as  it 
had  been  asserted  to  be  by  Dr.  B . . . I ascertained  that  there  was  a round  pessary 
with  a central  hole,  but  which  was  thickly  incrusted  with  calcareous  matter.  It  had 
been  applied  at  Vienna,  in  Austria,  after  her  last  confinement,  which  was  at  least  30 
years  before.  The  instrument,  which  was  but  little  altered,  having  for  a long  time 
given  rise  to  no  pain,  had  been  so  completely  forgotten  that  she  could  with  diffi- 
culty believe  in  its  presence  until  I showed  it  to  her  after  I had  extracted  it  by  intro- 
ducing a finger  into  the  hole  in  the  centre  of  the  pessary.  For  the  relief  of  the  pain 
and  inflammation  I prescribed  baths  and  emollient  injections  combined  w'ith  chloride 
of  lime;  enemata,  of  a soothing  and  narcotic  kind,  for  the  bowels,  and  from  that 
period  her  health  has  been  good — the  prolapsus  did  not  return,  notwithstanding  that 
no  pessary  has  been  since  made  use  of. 


INCONVENIENCES  OF  THE  PESSARY. 


147 


the  reduction  was  attempted,  but  in  vain  until  after  the  ivory  ring 
had  been  divided  with  a saw.  Augustin  Roux,  Journ.  de  M£d.  et  de 
Chirurg.,  Jan.  1778,  relates  that  he  was  obliged  to  make  use  of  a 
forceps  to  extract  a pessary  of  this  sort. 

Another  very  bad  effect  of  pessaries  is,  that  they,  especially  the 
bilboquet,  are  found  sometimes  to  injure  the  walls  of  the  vagina,  and 
occasion  a perforation  to  take  place  through  the  bladder  or  the  rectum, 
or  both  at  once ; thus  giving  rise  to  recto  and  vesico-vaginal  fistulas, 
the  consequences  of  which  are  so  much  the  more  deplorable  as  they 
are  frequently  beyond  the  reach  of  art  to  cure  them.  These  perfora- 
tions may  take  place  rapidly  where  the  inflammation  is  very  active  ; 
the  pressure  mortifies  the  parts  pressed  upon,  which  become  gan- 
grened, and  separate  in  sloughs,  through  which  the  instrument  passes. 

Sabatier*  relates  that  Camper  communicated  to  the  Academy  of 
Surgery  a case  in  which  the  surface  of  a bilboquet  pessary  was  found 
to  be  quite  diminished  and  the  stem  bent.  The  same  author  adds, 
that  ivory  pessaries  are  not  only  subject,  in  process  of  time,  to  corrode 
and  become  altered,  but  that  they  may  also  become  covered  with 
calcareous  incrustation.  The  celebrated  author  of  La  Medecine  Ope- 
ratoire , (loc.  cit.)  also  remarks,  in  speaking  of  a pessary  which  he 
was  obliged  to  cut  in  two  with  strong  pincers  before  he  could  succeed 
in  extracting  it,  that  it  was  covered  with  saline  incrustation  as  rough 
as  a rasp,  so  as  even  to  wound  his  fingers.  Jh.  Nollett  and  Pouteauj; 
relate  cases  of  the  same  kind,  and  express  themselves  in  terms  simi- 
lar to  those  used  by  Sabatier. 

Professor  Berard  found  great  difficulty  in  extracting  a bilboquet 
pessary  which  had  lost  its  stem,  and  which  had  perforated  both  the 
rectum  and  the  bladder.  M.  Lisfranc,  in  a similar  case,  was  obliged 
to  procure  an  opening  into  the  rectum  by  dividing  the  perineum,  and 
the  anterior  part  of  the  anus.  By  this  means  he  succeeded  in  ex- 
tracting the  pessary  with  pincers ; but  the  patient  fell  a victim  to  an 
attack  of  peritonitis.§  [Jour.  ZJniv.  Hebd.  de  Med.  t.  i.  p.  263.) 

In  the  Diet,  des  Sciences  Med.,  t.  vii.  p.  47,  the  following  case  is 
found.  A country  woman  had,  for  many  years,  worn  a pessary  en 
bilboquet,  which  she  did  not  extract  because  she  never  experienced 
any  inconvenience  from  its  presence.  In  process  of  time,  as  she  was 
now  suffering  violent  pains,  she  endeavoured  to  extract  the  instru- 
ment by  pulling  at  the  stem,  which  became  detached,  leaving  the 
circle  within  the  vagina.  The  distress  had  gradually  increased,  and 
she  at  length  found  that  a portion  of  her  fasces  as  well  as  of  her  urine 
came  away  through  the  vagina.  Having  got  admission  to  the  Hotel 
Dieu,  in  hopes  of  a treatment  for  her  disgusting  and  painful  disorder, 
she  came  under  the  care  of  Professor  Dupuytren,  who  ascertained,  in 
an  examination  per  vaginam,  that  the  circle  of  the  pessary  was  ex- 
posed in  the  rectum,  and  that  it  was  also  partly  in  the  bladder,  which 
it  had  perforated,  as  he  ascertained  by  means  of  a sound  introduced 
into  that  organ.  All  attempts  to  extract  the  pessary  with  the  fingers 

* Mem.  de  l’Acad.  de  Chir.,  t.  iii.  p.  33.  f Observat.  Chirurg.,  33. 

* CEuvres  Posthumes,  tom.  iii.  § Revue  Med.,  tom.  i.  p.  37,  1831. 


148 


INCONVENIENCES  OF  THE  PESSARY. 


having  been  frustrated,  Dupuytren  was  more  successful  by  the  use  of 
a strong  pincers,  with  serrge,  and  which  had  been  constructed  for  this 
very  purpose.  Rest,  and  the  use  of  a sound  in  the  bladder,  where  it 
was  maintained  for  three  weeks,  cured  the  woman  of  both  her  vesical 
and  rectal  fistula.  Mauriceau  tells  us  that,  “ in  1696,  he  extracted 
from  a woman  sixtv-seven  years  of  age,  a large  ivory  pessary  consist- 
ing of  a ring,  which  a truss-maker  had  adjusted  for  her  on  account 
of  a falling  of  the  womb.  She  had  worn  it  for  twenty  years  without 
having  suffered  any  inconvenience  from  it;  but  for  the  two  last  years 
she  had  been  subject  to  a great  defluxion  of  humours  upon  this  part; 
a disposition  to  ulceration  had  also  manifested  itself,  with  a profuse 
discharge  of  purulent  matter  mixed  with  blood ; and  this  had  con- 
tinued for  six  months,  so  that  the  patient  had  become  very  weak.” 

In  speaking  on  the  subject  of  pessaries  without  stems,  Sabatier, 
(loc.  cit.)  says,  “ that  if  the  instrument  is  large  enough  to  rest  upon  the 
sacrum,  and  to  resist  the  impulse  that  tends  to  expel  it,  it  produces  a 
retention  of  urine,  a difficulty  in  passing  the  faeces,  great  pain,  and 
tension  of  the  belly.  If,  on  the  other  hand,  the  pessary  is  too  small 
for  the  vagina,  the  weight  of  the  womb  and  superincumbent  viscera 
force  it  downwards,  upon  the  least  effort  made  by  the  woman  at 
urine  or  stool ; or  else,  in  spite  of  its  presence,  the  patient  has  a con- 
stant feeling  of  weight  at  the  hypogastrium,  dragging  sensation  in  the 
loins,  and  pains  in  the  thighs,  which  sometimes  make  it  out  of  the 
question  for  her  to  walk.”  Sponge  pessaries,  unless  removed  and 
washed  every  day,  are  also  very  objectionable,  as  the  fluids  from  the 
womb  and  vagina,  with  which  the  sponge  cells  are  filled,  undergo 
decomposition  very  rapidly.  Even  the  sponges  themselves  soon 
become  putrid,  and  the  high  temperature  of  the  vagina,  produced  by 
the  inflammation,  hastens  the  progress  of  these  changes.  We  may 
expect  to  have  sanious  and  foetid  secretions;  whereupon  intense  fever 
attacks  the  patient,  and  all  the  symptoms  of  purulent  absorption  are 
disclosed.  Dr.  Grenier,  in  his  Inaugural  Dissertation , relates  the 
following  case : During  the  month  of  May,  1832,  M.  Brodie,  of  Lon- 
don, one  of  the  most  celebrated  of  the  English  surgeons,  was  called  to 
a lady  who  had  forgotten  a small  sponge  in  the  vagina.  He  found  her 
labouring  under  the  incontestable  symptoms  of  typhoid  fever,  with 
marked  prostration,  ftetor  of  the  excretions,  &c.  In  consequence  of  the 
nature  and  the  abundance  of  the  vaginal  secretions,  he  suspected,  and 
at  last  discovered  the  cause  of  the  malady.  He  immediately  extracted 
the  remains  of  the  sponge,  which  came  away  piecemeal;  and  he  then 
prescribed  frequent  injections  of  chlorides,  and  treated  her  as  if  com- 
bating a typhoid  fever.  The  symptoms  were  amended  upon  removing 
the  cause,  but  the  patient  recovered  very  slowly.  Were  it  not,  in  fine, 
that  we  fear  being  found  too  prolix  upon  this  point,  we  could  add  to 
the  numerous  Samples  we  have  already  brought  forward,  a great 
many  cases  fitted  to  set  forth  the  accidents  that  may  supervene  upon 
the  employment  of  the  pessary. 

Inasmuch  as  the  use  of  these  instruments  is  far  from  being  always 
safe,  they  ought  only  to  be  employed  in  cases  of  absolute  necessity. 


INCONVENIENCES  OF  THE  PESSARY. 


149 


A very  good  substitute  for  them  is  in  fact  found 
in  the  astringent  sachets  recommended  by  Osi- 
ander,  or  in  fine  sponges  that  should  be  re- 
moved at  night,  and  carefully  washed  before 
they  are  replaced.  I have  had  a sort  of  bag 
made  of  pure  India  rubber,  filled  with  air, 
which,  although  very  supple  and  light,  supports 
the  parts  very  well,  without  irritating  them. — 

( Vide  fig.  18.)  Besides,  as  these  sachets  are 
shaped  somewhat  like  the  male  organ,*  and  as 
they  can  be  varied  as  to  length  and  diameter, 
they  adapt  themselves  to  the  vagina,  and  may 
be  retained  by  means  of  the  T bandage  or  by 
the  napkin  usually  worn  during  the  catamenia. 

These  priapiform  pessaries  being  easy  to  adjust  or  remove,  ought  only 
to  be  made  use  of  in  the  day  time,  while  the  patient  is  out  of  bed  ; but, 
in  order  to  prevent  the  womb  from  falling,  even  for  a short  time,  the 
instrument  ought  to  be  adjusted  before  leaving  the  bed.  If  the  other 
kinds  of  pessaries  could  be  made  use  of  in  the  same  way,  the  radical 
cure  of  a prolapsion  in  the  first  or  even  second  stage  would  often  be 
effected  in  the  course  of  a few  months. 

The  irritation  and  inflammation  excited  by  the  application  of  the 
pessary  ought  to  be  counteracted  by  rest,  by  diet,  baths,  enemata, 
emollient  and  opiate  injections,  and  invariably  by  a temporary  sus- 
pension of  the  use  of  the  instrument. 

Women  accustomed  to  the  use  of  the  pessary,  should  never  lose 
sight  of  the  fact,  that  the  presence  of  such  an  instrument  in  the  vagina 
requires  the  most  scrupulous  attention  to  cleanliness.  They  should 
frequently  bathe,  and  they  should  have  recourse  to  injections  of  cool 
water,  or  a mixture  of  wine  and  water,  twice  a day.  They  should 
also  remember  that  the  instruments  ought  to  be  removed  at  least 
once  a fortnight,  in  order  to  be  replaced  or  repaired  in  case  of  its 
appearing  to  be  necessary. 

We  shall  close  our  observations  upon  this  subject  by  the  remark, 
that  in  many  cases,  especially  recent  ones,  of  prolapsus,  the  displace- 
ment might  be  cured  by  means  of  astringent  injections  and  fomen- 
tations with  articles  of  which  tannin  should  constitute  the  chief 
ingredient,  and  which  may  be  rendered  still  more  active  by  adding 
alum,  or  white  or  green  vitriol ; or  the  patient  might  try  the  effect  of 
a small  tampon,  made  of  fine  linen  or  sponge,  impregnated  with  the 
same  substances,  and  introduced  two  or  three  times  a day  into  the 
vagina,  and  left  there  about  half  an  hour  each  time. 

COMPLICATIONS  CONTRA-INDICATING  THE  USE  OF  THE  PESSARY, 
AND  INDICATIONS  IN  CERTAIN  PECULIAR  CASES. 

We  have  said  before  that  certain  complications  may  exist  that  lead 

* The  ancient  Greek  physicians  made  use  of  pessaries  like  those  just  mentioned 
of  the  form  and  length  of  the  male  organ,  which  is  the  reason  why  they  are  called 
wgiciTrts-xwTa,  or  priapiform  pessaries. 


Fig.  18. 


150 


PARTICULAR  INDICATIONS,  ETC. 


us  to  reject  the  employment  of  the  pessary,  and  that  chronic  vaginitis 
and  metritis  require  an  antiphlogistic  treatment,  as  preliminary  to  the 
employment  of  the  instrument.  Nevertheless,  a superficial  excoria- 
tion or  ulceration  of  the  vagina  does  not  always  contra-indicate  the 
pessary,  as  was  supposed  by  Ruysc  hand  Boyer  ; for  the  reduction 
of  the  womb  often  cures  the  vaginal  inflammation  which  had  been 
produced  by  the  prolapsion.  On  the  other  hand,  a cancer  situated 
upon  the  neck  or  body  of  the  womb  in  prolapsion,  would  forbid  the 
use  of  the  pessary,  whether  from  its  increasing  the  irritation  and  pain, 
or  whether  the  reduction  of  the  womb  would  deprive  us  of  the 
facilities  and  warrants  of  success  resulting  from  different  operations, 
among  which  I may  mention  cauterization,  excision  of  the  cervix,  or 
the  absolute  ablation  of  the  cancerous  organ. 

Should  cancerous  ulcerations,  situated  upon  the  cervix,  from  their 
slightness,  not  contra-indicate  the  reduction  of  the  womb,  it  ought  to 
be  supported  by  a fine  sponge,  frequently  renewed,  as  the  most 
fitting  support  in  such  a case. 

Where  a polypus  exists  coincidently  with  a prolapsion,  the  polypus 
ought  to  be  removed  before  any  attempt  at  reduction  is  made,  which 
then  becomes  an  easy  task:  wherever,  also,  there  happens  to  be  a 
calculus  in  the  bladder,  complicated  with  falling  of  the  womb,  we  are 
advised,  both  by  Ruysch  and  Dug6s,  to  remove  thb  calculus  by  a 
direct  incision.  Lastly,  where  the  prolapsus  takes  place  in  the  first 
months  of  pregnancy,  the  reduction  should  be  at  once  effected,  and 
the  organ  retained  in  situ  by  means  of  a pessary,  or  the  woman 
should  be  prevailed  upon  to  lie  in  bed  during  the  first  periods  of 
gestation.  Means  of  support  and  rest  are  equally  useless  subsequent- 
ly to  the  fourth  month,  for  at  that  stage  the  womb,  though  in  the 
second  stage  of  procidentia,  has  acquired  a magnitude  sufficient  to 
retain  it  above  the  superior  strait. 

In  a case  in  which  the  precipitation  has  taken  place  and  existed 
throughout  the  whole  of  the  pregnancy,  we  must  assist  nature  in  the 
delivery,  and  follow  the  example  set  by  Mauriceau,  Portal,  Ducreux 
and  Wagner,  who,  after  gently  dilating  the  thinned  circle  of  the  os 
uteri,  carried  in  the  hand,  in  order  to  deliver  the  child  and  the  secun- 
dines  also,  and  then  reduced  the  womb,  now  contracted  and  dimi- 
nished in  size.  Where  the  lips  of  the  os  tincse  happen  to  be  affected 
with  an  induration,  preventing  the  dilatation  of  the  neck,  the  orifice 
may  be  enlarged  by  means  of  two  or  three  incisions,  made  with  a 
probe-pointed  bistoury ; cases  of  prolapsus  in  complication  with  both 
induration  and  pregnancy,  are  very  rarely  to  be  met  with,  for,  up  to 
this  time,  they  have  been  noticed  only  by  Marignes,  of  Versailles,  by 
Choppart,  and  our  skilful  accoucheur,  M.  Capuron. 

CURE  OF  PROLAPSUS  UTERI. 

The  curative  treatment  of  uterine  prolapsus  is  rarely  followed  by 
complete  success.  With  a view  to  the  radical  cure  of  the  disorder, 
a great  variety  of  measures,  more  or  less  efficacious,  have  been 
recommended,  and  among  them  protracted  rest,  and  decubitus ; par- 


IN  THE  USE  OF  THE  PESSARY. 


151 


ticularly  observing  to  keep  the  pelvis  elevated  higher  than  the  shoul- 
ders ; the  use  of  pessaries,  gradually  reducing  the  size  of  the  instru- 
ment; aromatic  and  astringent  injections;  cold  bathing;  sachets 
filled  with  tan  and  soaked  in  rough  wine ; and  lastly,  the  tampon, 
composed  of  styptic  and  astringent  materials. 

Some  authors,  particularly  M.  Delloir,  have  recommended  a sub- 
sequent pregnancy  as  an  excellent  means  of  obtaining  a radical  cure 
of  hysteroptosis ; without  adopting  absolutely  the  opinions  set  forth 
upon  this  point,  we  think  that  the  increase  of  the  volume  resulting 
from  gestation,  could  be  of  no  avail,  unless  the  patient  should  con- 
sent to  maintain  a horizontal  position  during  the  first  five  months  of 
the  pregnancy;  otherwise,  we  should  look  upon  the  state  of  preg- 
nancy as  an  hurtful  and  even  dangerous  one.  Besides,  we  must 
wait  until  experience  and  facts  shall  enable  us  to  speak  more  confi- 
dently of  the  value  pf  M.  Delloir’s  recommendation. 

[I  look  upon  it  that  many  women  recover  from  very  troublesome  prolapsus, 
by  a succeeding  pregnancy.  I have  seen  women  perfectly  restored  to  health 
after  a pregnancy  and  lying-in,  who  had  been  much  distressed  by  prolapsus 
for  some  years  before. — >M.] 

In  order  to  effect  a radical  cure,  it  has  also  been  proposed  to  obli- 
terate the  vagina,  by  making  the  sides  of  the  canal  cohere,  but  as 
the  mucous  membranes  cohere  very  reluctantly,  we  think  there  would 
be  great  difficulty  in  bringing  about  the  result  proposed.  The  diffi- 
culties met  with  in  the  cure  of  recto  and  of  vesico-vaginal  fistulas, 
justify  our  fears  on  this  point;  moreover,  an  acute,  though  factitious 
inflammation  of  the  vagina  would  not  be  wholly  safe,  and  might  lead 
to  very  serious  consequences. 

Dr.  Marshall  Hall  has  published  a case,  in  which  he  asserts  that 
he  cured  an  almost  complete  prolapsus  by  means  of  an  artificial  con- 
striction of  the  vagina.  He  removed  a portion  of  the  membrane 
eighteen  lines  wide,  from  the  top  to  the  bottom  of  the  vagina,  and 
united  the  edges  by  means  of  the  interrupted  suture.  Prof.  Duges 
expresses  a doubt  as  to  the  durability  of  success  from  this  operation, 
and  thinks  that,  notwithstanding  its  constriction,  the  vagina  may, 
after  all,  be  pushed  downwards,  dilated  and  prolapsed  again  by  the 
weight  of  the  womb.  We  do  not  indulge  in  all  the  fears  of  the  learned 
Montpellier  professor,  particularly  if  care  be  taken  to  relieve  the 
engorgement  of  the  womb,  which  is  most  generally  the  cause  of  its 
prolapsion.  Although  this  curative  method  is  the  most  painful,  yet 
it  appears  to  us  to  be,  above  all  others,  the  most  likely  to  lead  to  a 
radical  cure.  One  thing  is  certain ; the  operation,  the  first  idea  of  which 
appears  to  have  originated  with  M.  Girardin,  has  been  successfully 
performed  in  France,  by  M.  Berard,  and  in  England,  by  Mr.  Irving. 

[It  has  been  twice  performed  here,  by  Dr.  William  Poyntell  Johnston. 
The  success  was  complete;  but,  in  both  instances,  the  disorder  returned  in 
about  six  months. — M.] 


152 


EXTIRPATION  OP  THE  PROLAPSED  WOMB, 


EXTIRPATION  OF  THE  PROLAPSED  WOMB. 

We  shall  finish  our  remarks  upon  this  topic  by  stating  that,  on  some 
occasions,  the  more  or  less  complete  extirpation  of  the  womb  has 
been  successfully  performed,  where  the  prolapsed  womb  has  been 
found  either  in  a state  of  gangrene  or  of  cancerous  degeneration. 
This  operation,  to  which,  as  Astruc*  says,  we  must  never  resort 
but  in  the  last  extremity,  in  evidenti  mortis  periculo,  was  anciently 
practised  with  success,  as  related  by  various  authors,  as  Aetius,  t 
Paul  of  Egina,J  Berengarius  Carpus, § J.  Langius,||  Marcus  Gattina- 
ria,1F  Ant.  Benevenius,**  Christophus  a Vega, It  Ambrose  Par6,JJ 
and  many  others  too  tedious  to  mention. 

Soranus,  who  was  distinguished  among  the  ancient  authors  for  the 
fortunate  temerity  of  his  operations,  recommends  that  the  prolapsed 
and  putrified  womb  should  be  extirpated.  “ If/’  says  he,  “the  pen- 
dant portion  of  the  womb  becomes  ulcerated  from  the  acrimony  of 
the  urine  and  the  uncleanness  of  the  parts ; if  it  putrefies,  extirpate 
it  without  hesitation ; you  are  warranted  by  example  to  do  so  ; it  has 
been  completely  extirpated  in  some  instances  with  the  most  perfect 
success.”  (Aetius,  Tetrab.  iv.,  Serm.  4.  cap.  76;  and  Peyrille,  Hist,  de 
la  Chir.  t.  ii.  p 2S2.) 

The  gangrenous  prolapsed  womb  has  also  been  removed  by  a sin- 
gle ligature  applied  at  the  pedicle,  or  with  a double  ligature,  each 
comprising  one  half  of  the  root  of  the  tumour.  This  method,  two 
successful  cases  of  which  are  given  by  F.  Rousset,§§  has  also  been 
practised  by  Newnham,  Clarke,  Marshall,  Windsor,  Recamier,  and 
by  some  other  distinguished  practitioners.  Lastly,  when  the  prolapsed 
womb,  in  a state  of  disorganization,  leaves  no  hope  from  any  other 
method  of  treatment,  resort  has  been  had  to  a ligature  at  the  root  of 
the  tumour,  and  the  excision  of  all  beyond  it.  This  proceeding  has 
been  successfully  adopted  by  Carpus,  by  A.  Pare,  by  Baxter,  and  by 
Bernhard. 

METHOD  OF  OPERATING. 

Although  the  excision  of  the  womb,  which  has  been  long  in  a 
state  of  complete  prolapsus,  is  a very  terrible  operation,  viewed  in 
the  light  of  its  immediate  or  remote  consequences,  we  shall  proceed 
to  give  a brief  description  of  the  different  modes  of  operating  em- 
ployed for  the  purpose. 

M.  R6camier||||  begins  with  the  vagina;  then,  his  first  incision 
being  made,  he  separates  the  celtular  tissue  with  his  fingers,  until  he 
comes  to  the  peritoneum : he  next  divides  the  upper  two-thirds  of 

* Maladies  des  Femmes,  liv.  ii.  t.  iii.  p.  409.  j-  Tetrabib.,  iv.,Serm.  iv.,  cap.  76. 

X Lib.  iii.  cap.  76,  and  lib.  vi.  cap.  6 & 22.  § In  Isagoge  Anatomic:). 

||  Epist.  Med.,  epist.  39.  1 Prat.  Cap.  de  Exiiu  Matricis. 

**  Observ.  Med.,  obs.  ix.  de  Mirand  Morb.  Caus.,  cap.  12. 

jj-  Comment,  ad  Aphorism.  IS.  lib.  viii.  t+  LXXIV.  cap.  xxviii. 

§§  De  Partu  Csesareo,  liber,  p.  393.  ||||  Rev.  Med.,  1825,  t.  iv.  p.  393. 


EXTIRPATION  OF  THE  PROLAPSED  WOMB. 


153 


the  ligaments,  and,  by  means  of  Deschamp’s  needle,  passes  a liga- 
ture round  the  inferior  third,  which  contains  the  uterine  artery — and 
finishes  the  operation  by  removing  the  organ.  This  mode,  which 
was  adopted  by  MM.  Recamier  and  Marjolin,  upon  a woman  with  a 
bad  prolapsion,  and  who  also  had  a fungous  cancer  of  the  womb,  was 
followed  by  imperfect  success ; for  the  patient  died  two  months  after 
the  operation. 

Professor  Delpech,*  whose  recent  loss  is  so  much  to  be  deplored, 
made  use  of  this  same  operation  in  a female  aged  sixty-six : he  pro- 
ceeded as  follows:— the  patient  having  been  placed  as  for  lithotomy, 
he  first  carefully  divided  the  whole  anterior  wall  of  the  vagina, 
which  had  been  attacked  with  cancer;  then,  after  having  cautiously 
separated  the  anterior  part  of  the  rectum,  which  was  also  affected, 
he  removed  the  tumour,  which  was  completely  isolated;  he  applied 
ligatures  to  the  divided  arteries,  and  filled  the  vacuum  left  betwixt 
the  remaining  vaginal  walls  with  fine  sponge,  for  the  purpose  of 
keeping  them  apart. 

Langenbeck’s  method  differs  from  the  above,  in  regard  that  that 
able  surgeon  deems  it  useful  to  dissect  the  whole  uterine  peritoneum 
off  from  without  inwards,  so  that  the  serous  membrane  is  not 
wounded  by  the  removal  of  the  womb.  This  operation  was  done  by 
M.  Langenbeck  for  a female  affected  with  incomplete  prolapsus  uteri, 
and  with  scirrhous  degeneration  of  the  womb,  and  was  crowned  with 
the  most  perfect  success,  for  the  woman’s  health  was  completely 
restored.  The  removal  of  the  womb  by  this  method  is  so  long  and 
difficult  that  we  hardly  think  M.  Langenbeck  will  find  any  imitators, 
particularly  as  we  are  not  convinced  of  the  necessity  for  dissecting 
off  the  whole  of  the  peritoneum,  that  necessity  not  having  been 
demonstrated. 

The  removal  of  the  womb  by  the  ligature  is  very  painful,  and  is 
attended  with  a risk  of  there  being  comprehended  within  the  ligature, 
either  the  urethra,  as  in  the  case  seen  by  Ruysch,  or  a loop  of  the 
intestine,  or  even  a portion  of  the  urinary  bladder.  With  a view  to 
render  the  extirpation  less  painful,  and,  at  the  same  time,  to  secure  a 
more  prompt  separation,  Faivre  and  Windsor  both  made  use  of  a nee- 
dle, armed  with  a double  ligature,  by  which  the  neck  of  the  tumour 
was  strangulated  in  two  equal  halves.  If,  notwithstanding  all  the  ob- 
jections we  have  mentioned,  the  operator  should  still  desire  to  proceed 
by  the  method  of  strangulation,  we  should  think  it  better  at  once  to 
remove  all  the  substance  of  the  mass  beyond  the  ligature,  whether  it 
be  a simple  or  double  one,  and  not  wait  for  a separation  produced  by 
the  ordinary  sloughing  process  under  the  ligature.  For  fear  of  impli- 
cating the  bladder  or  an  intestinal  convolution,  the  pelvis  ought  to  be 
shaken  before  commencing  the  operation  ; anc^  it  should  be  elevated 
upon  a cushion,  so  as  to  be  higher  than  the  rest  of  the  trunk.  How- 
ever, where  the  extirpation  of  the  womb  affords  the  only  chance  of 
safety  to  the  patient,  we  think  the  knife  preferable  to  the  ligature,  as 
being  less  painful  and  more  prompt,  and  as  offering,  besides,  a greater 


t Memorial  des  Hopitaux  du  Midi.,  t.  ii.  p.  612. 


154 


ANTEVERSION  AND  RETROVERSION. 


proportion  of  successful  results  than  the  other  methods  of  ablation 
that  have  been  used. 

OF  ANTEVERSION  AND  RETROVERSION  OF  THE  WOMB. 

The  terms  anteversion  and  retroversion  have  been  applied  to  those 
cases  in  which  the  longitudinal  axis  of  the  uterus  has  been  found 
placed  in  a horizontal  position. 

As  these  two  uterine  displacements  exhibit  a close  analogy  to 
each  other,  as  far  as  regards  their  causes,  symptoms  and  treatment, 
we  have  thought  it  best  to  speak  of  them  under  one  head,  so  as  to 
throw  more  light  upon  the  subject  and  obtain  more  precision  in 
detailing  the  history  of  the  cases  by  studying  them  together. 

In  anteversion  of  the  womb,  the  fundus  is  borne  towards  the  sym- 
physis pubis,  and  the  os  uteri  towards  the  sacrum.  In  retroversion, 
the  womb  likewise  becomes  horizontal,  but  the  fundus  is  lodged  in 
the  hollow  of  the  sacrum,  and  the  mouth  of  the  womb  is  carried  to 
the  posterior  surface  of  the  symphysis  of  the  pubis. 

The  writings  of  Hippocrates  contain  many  passages,  proving  that 
the  deviations  of  the  position  of  the  womb  had  caught  his  attention ; 
and  it  is  not  to  be  doubted  that  he  was  referring  to  retroversion  of 
the  uterus,  where  he  said,  Si  uteri  ad  medios  lumbos  fuerint,  dolor 
imum  ventrem,  deinde  crura  detinet ; cumque  ventris  onus  deponit, 
acutiores  suboriuntur,  stercusque  non  nisi  vi  progreditur,  urina  gut- 
tatim  fertur,  et  animo  linquitur,  &c.* 

In  the  fragments  extracted  from  the  works  of  Aspasia,  ( De  reclina - 
tione'ciscens.  et  recurs,  uteri,)  preserved  by  Aetius,t  we  find  her 
speaking  very  distinctly  on  the  subject  of  retroversion,  for  which  she 
indicates  a rational  mode  of  treatment,  which  we  shall  make  known 
presently. 

In  his  work  on  the  diseases  of  women,  published  in  1604,  Rod. 
a Castro,  a Portuguese  Jew  physician,  who  studied  at  Salamanca, 
and  afterwards  emigrated  to  Hamburg,  where  he  died,  gives  us  an  • 
imperfect  version  of  the  remarks  of  Hippocrates  and  Aspasia  upon 
retroversion  of  the  womb.  Israel  Spach,  who  was  professor  at 
Strasburg,  and  collected  all  that  had  been  written  previous  to  his 
time,  on  female  complaints,  likewise  speaks  of  uterine  displacements, 
in  his  work,  published  in  1597,  under  the  title  of  Gynceciorwn , Sive 
de  Mulierum , Jlffcctibus  et  Morbis.  Since  the  days  of  these 

authors,  Gregoire,  a Paris  surgeon,  was  the  first  to  speak  particularly 
of  retroversion  and  anteversion.  He  taught  these  displacements  in 
detail,  to  the  pupils  of  his  course  on  midwifery ; and  it  was,  in 
fact,  to  the  lectures  of  this  professor,  that  Walter  Wall,  the  English 
surgeon,  was  indebted  for  his  first  notions  on  the  displacements  of 
the  womb.  Upon  returning  to  his  own  country,  he  was  consulted, 
in  1754,  for  a case  of  retroversion.  He  recollected  the  precepts  of 
Gregoire,  and  requested  the  celebrated  Hunter  to  assist  him  with  his 
counsel ; notwithstanding  which,  the  patient  sunk  on  the  eighth  day. 

* De  Natur.  Ma).  Op.,  t.  ii.  p.  542.  Ed.  Kultn. 
f Tetrabib.,  i\\,  Serm.  iv.,  pp.  76  and  77. 


ANTE  VERSION  AND  RETROVERSION. 


155 


Hunter,  considering  this  affection  to  be  worthy  of  the  regard  of 
the  profession,  made  it  the  subject  of  a monograph,  which  he  pub- 
lished in  1770,  in  the  4th  vol.  of  the  Med.  Obs.  and  Inquiries , and 
gave  it  the  name  of  retroversion , which  has  been  ever  since  gene- 
rally adopted.  Walter  Wall  and  Syme  called  it  hernia  uteri.  Levret 
designated  it  as  renversernent  transversal ; and  Desgranges,  as  in- 
cubation. 

Since  the  publications  of  Hunter  and  Syme,  a multitude  of  writers 
have  put  forth  their  observations  upon  the  subject,  as  Levret,* 
Wlzezech,t  Wall,J  Desgranges, § whose  memoir  was  crowned  in 
1783,  by  the  Academy  of  Surgery  ; Fred.  Jahn,||  Cockell,1[  Murray,** 
Baudelocque,tt  Merriman,ff  G.  I.  Schweighauser,§§  Schmidt, ||||  and 
Ameline.lFIT  There  are  a great  number  of  observations  published 
in  various  collections,  from  Richter,***  Garthshore,  Bird  and  Hoop- 
er,ttt  J.  Clarke,tfl  Klein, §§§  Schneider,||||||  Kirshner,innr  Brun- 
ninghausen,****  Hervez  de  Ch6goin,tttt  Madame  Boivin  and  M. 
Duges;±ff  ± by  M.  Bazin  de  Basseneville  ;§§§§  and  by  other  persons 
whom  it  is  needless  to  cite.  Both  anteversion  and  retroversion  may 
take  place  in  the  non-gravid  womb,  and  also  during  pregnancy;  but, 
in  general,  the  deviations  in  question,  and  which  are  always  more 
considerable  in  the  retroversion,  cannot  take  place  later  than  the 
fourth  month  of  pregnancy,  because,  at  that  period,  the  longitudinal 
diameter  of  the  organ  exceeds  the  antero-posterior  diameter  of  the 
pelvis. 

Anteversion  of  the  womb,  though  very  rare  in  pregnancy,  is  of  pretty 
frequent  occurrence  in  the  non-gravid  female.  Retroversion,  on  the 
other  hand,  has  most  frequently  been  met  with  in  pregnant  women. 
Frederick  Jahn  did  not  admit  that  retroversion  could  be  complete 
except  in  pregnancy ; but  Levret  and  Saxtorph  proved  by  very  well 
ascertained  cases  that  it  may  occur  not  only  in  women  who  have 
never  had  children,  but  even  in  the  virgin.  Dr.  Schweighauser,  of 
Strasburg,  met  with  forty-four  cases  of  retroverted  womb:  thirty-five 

* Remarques  sur  les  Deplacements  de  la  Matrice.  Ancien.  Jour,  de  Med.,  t.  xl. 

f De  Utero  Retroflexo,  1777.  t Diss.  de  Uteri  Retrovers.,  1782. 

§ Journ.  de  Med.,  t.  lxvi.  p.  85.  ]|  De  Utero  Retroverso,  1787. 

U Essay  on  Retroversion  of  the  Uterus,  1785. 

**  Uteri  Retroversionum  Animadversiones,  1797. 

ft  Du  Renversernent  de  la  Matrice,  1803. 

ft  On  Retroversion  of  the  Womb,  1810.  §§  Aufsaetze  fiber  einige,  &c.,  1817. 

HU  Bemerkungen  undErfahr.;  i.  e.,  Observations  and  Experiments  on  Retroversion. 
Vienna,  1820. 

UU  Diss.  sur  1’ Anteversion.  Paris,  1827.  No.  55. 

***  Chirurg.  Biblioth.,  b.  v.  p.  521 ; b.  ix.  p.  182. 

-f-ff  Med.  Obs.  and  Inquir.,  t.  iv.,  v.  andvii. 

fft  Pract.  Essay  on  the  Management  of  Pregnancy  and  Labour. 

§§§  Chirurg.  Bemerkungen,  p.  235.  ' III II  Chirurg.  Biblioth..  Richter,  1791. 

Stark’s  Archiv.  fur  die  Geburtshulfe,  b.  iv.  st.  3.  637. 

****  Journal  de  Siebold,  b.  iii.  st.  1.  ann.,  1819. 

•fj-j-f-  Mem.  de  l’Acad.  de  Med.,  t.  ii.  319,  1833. 

tttt  Traite  des  Mai.  de  l’Uterus,  1833. 

§§§§  Mem.  sur  la  Retroversion.  Annales  franc,  and  etrangeres,  d’Anat.  and  de 
Physiol.,  Mars.,  1837.  Paris,  Levrault. 


156 


ANTE  VERSION  AND  RETROVERSION. 


were  in  women  not  pregnant,  and  only  five  were  met  with  in  gravid 
females.  Among  the  thirty-five  mentioned  there  was  one  female 
seventy-two  years  of  age;  one  ease  was  noticed  following  delivery, 
and  one  wa£  in  a virgin  with  the  hymen  perfect.  Dr.  Bazin  de 
Basseneville,  who  has  given  these  results  from  Schweighauser,  has 
likewise  published  in  the  Jlnnales  Francaises  etrcing&res  d?Anat. 
et  Physiologie  (March  1837)  several  cases  of  retroversion,  in  women 
without  children  or  virgins.  Most  of  these  cases,  endowed  with  all 
desirable  authenticity,  are  taken  from  the  practice  of  Messrs.  Brun- 
ninghausen  of  Wurtzburg,  Schmitt  of  Vienna,  Schneider  of  Balby, 
and  Kirschner  of  Poeneck ; and,  in  fine,  the  Treatise  on  diseases  of 
the  womb  by  Mad.  Boivin  and  M.  Dug6s  contains  three  cases  of  retro- 
version in  patients  not  gravid.  The  displacement  therefore  is  not  so 
rare  in  non-pregnant  women  as  it  has  been  supposed  to  be. 

Both  anteversion  and  retroversion  may  take  place  either  gradually 
or  suddenly.  In  the  first  case,  the  symptoms  are  slight  in  the  beginning, 
and  daily  increase  in  severity,  following,  in  this  respect,  the  progress 
of  the  accident ; but  in  the  second  case,  the  deviation  of  the  womb  is 
accompanied  at  once  with  alarming  symptoms,  particularly  if  it  be  a 
retroversion.  The  causes  that  predispose  to  gradual  displacements 
are  a natural  mobility  of  the  womb,  a certain  smallness  of  the  pelvis, 
a deep  curvature  of  the  sacrum,  a decided  prominence  of  the  sacro- 
vertebral  angle,  the  gentle  and  prolonged  pressure  of  the  bowels  upon 
the  fundus  and  on  one  of  the  surfaces  of  the  womb.  The  symptoms 
that  supervene  have  less  reference  to  the  extent  of  the  deviation  than  to 
the  volume  of  the  womb  as  compared  to  the  antero-posterior  diameter 
of  the  pelvis.  Supposing  the  womb  to  be  non-gravid,  and  the  cavity  of 
the  pelvis  of  the  ordinary  dimension,  if  the  displacement  takes  place 
gradually,  the  patient  begins  to  feel  an  inconvenient  sense  of  pressure 
within  the  pelvis ; then  the  groins,  the  loins,  and  thighs,  are  affected 
little  by  little  with  dragging  pains,  which  become  more  and  more 
annoying.  Soon  after  this  the  signs  of  inflammation  of  the  womb 
become  manifest,  and  the  suffering  more  acute;  the  catamenia  become 
disordered, either  increasing  or  diminishing  in  quantity;  a leucorrhoea, 
which  in  some  instances  is  bloody,  flows  during  the  intervals  between 
the  menses ; the  digestion  is  deranged  ; the  appetite  is  lost ; the  woman 
grows  thin,  and  her  strength  diminishes.  At  length  a fever  sets  in, 
which,  in  some  cases,  is  of  a high  grade  and  of  a continued  type;  but 
in  others,  slight,  and  characterized  only  by  heat  of  the  skin,  and  by 
agitated  evenings  and  nights.  If  the  cessation  of  the  menses  takes 
place  naturally,  the  woman  being  at  the  change  of  life,  the  uterine 
deviation  may  cease  to  have  any  influence  on  the  constitution  ; and 
in  many,  the  symptoms  gradually  lessen,  because  the  womb  has 
diminished  in  size  by  losing  a portion  of  its  vital  properties. 

To  the  symptoms  above  mentioned,  there  is  always  added  a sense 
of  pressure  or  weight  at  the  bladder  and  rectum,  giving  rise  to  fre- 
quent desire  to  urinate  and  go  to  the  close  stool.  During  the  flow 
of  the  urine,  the  jet  is  soon  checked  or  suddenly  arrested,  and  as  the 
displacement  always  increases  in  proportion  to  the  efforts  made  to 
expel  the  urine  and  faeces,  the  symptoms  are  greatly  augmented  in 


ANTEVERSION  AND  RETROVERSION. 


157 


intensity  by  those  attempts.  At  length  a complete  suppression  of 
urine  and  stool  is  produced.  In  cases  where  the  size  of  the  womb  is 
augmented  by  pregnancy  or  by  engorgement  of  the  organ,  the  symp- 
toms are  less  equivocal,  the  constipation  and  suppression  of  urine 
becoming  complete  in  a very  short  time : this  is  most  likely  to  happen 
between  the  third  and  fourth  months  of  pregnancy.  However,  from 
a case  published  by  Smellie;*  from  that  given  us  by  Hunter,!  and  from 
Meckel’s  case,  related  by  Voigtel,±  the  term  at  which  a deviation  is 
possible  may  be  stated  to  be  as  late  as  the  fifth  month.  A case  is 
related  from  Barlett,§  of  retroversion  at  the  seventh  month.  This, 
and  the  case  related  by  Merriman,||  who  thinks  he  has  met  with 
several  samples  of  this  deviation  even  at  the  end  of  pregnancy,  were 
doubtless  samples  of  posterior  obliquity  of  the  womb  which  have  been 
long  understood  under  the  title  of  sur-pubal  positions  or  posterior 
obliquity  of  the  foetus  ;1F  or  perhaps  they  were  extra-uterine  preg- 
nancies with  the  foetal  sac  pushing  the  womb  upwards,  out  of  reach 
nearly  of  the  index  finger. 

Inasmuch  as  the  long  diameter  of  the  womb,  at  the  end  of  the  fourth 
month,  equals  or  even  exceeds  the  antero-posterior  diameter  of  the 
pelvis,  it  follows,  not  only  that  the  displacement  cannot  happen  after 
that  period,  but  that  where  it  has  already  existed  for  some  time,  the 
rectum,  the  neck  of  the  bladder,  and  the  urethra  must  be  compressed; 
and  that  the  womb,  locked  up  within  the  excavation,  and  moulding 
itself  against  the  resisting  surfaces,  becomes  engorged  and  inflamed ; 
thus  aggravating  the  already  dangerous  symptoms  of  retroversion. 

Where  the  retroversion  takes  place  suddenly,  it  is  almost  always 
caused  by  the  violent  and  sudden  contraction  of  the  abdominal  mus- 
cles and  diaphragm,  such  as  those  that  occur  in  the  act  of  vomiting 
or  in  the  expulsion  of  the  urine  and  stool;  such  as  arise  from  exter- 
nal violence,  as  a fall,  a blow,  strong  compression  of  the  hypogaster** 
or  a sudden  frighttt  causing  a violent  convulsive  movement  of  the 
diaphragm. 

It  is  easy  to  understand  why  the  displacement  of  the  womb  is  much 
more  rapid  in  its  progress,  and  followed  by  severer  consequences, 
in  women  that  are  pregnant.  But,  inasmuch  as  the  anteversion  of 
the  womb  is  exceeding  rare  during  gestation,  we  must  be  content 
with  adding  to  what  has  already  been  said,  merely  the  characteristic 
signs  of  retroversion  in  pregnant  females. 

The  causes  we  have  mentioned  as  sufficient  to  bring  about  the 
accident  in  the  non-gravid  female,  always  act  with  greater  force  upon 
such  as  are  pregnant.  According  to  Hunter,  Denman,  Merriman, 

* Treat,  on  Mid.,  vol.  ii.  p.  150.  t Icon.  Uteri  Ham.  Crav. 

* Desormeaux,  Diet.,  21  vol.,  article  Uterus,  p.  130. 

§ Bib.  Med.,  lxxvi.  p.  125. 

||  A Synopsis  of  Various  Kinds  of  Difficult  Parturition,  p.  66  and  244. 

t Prat,  des  Accouch.  de  Mad.  Lachapelle,  t.  iii.  p.  295. 

**  Desgranges  of  Lyons  in  his  memoir,  which  was  crowned  by  the  Acad,  of  Sur- 
gery, relates  a case  of  retroversion  caused  by  the  pressure  of  a kettle  full  of  wet 
clothes. 

ft  In  the  fourth  volume  of  the  Med.  Obs.  and  Inquiries,  Hunter  gives  us  the  history 
of  a young  woman  who  was  attacked  suddenly  with  the  symptoms  of  retroversion  in 
consequence  of  a great  fright. 


15S 


ANTE  VERSION  AND  RETROVERSION. 


Callisen,  Boer  and  Sibergundi,  the  retention  of  the  urine  in  the  blad- 
der is  the  most  common  cause  of  the  displacement  in  question.  This 
symptom,  which,  indeed,  is,  in  pregnancy,  one  of  the  first  that  an- 
nounces the  existence  of  retroversion,  may  be,  at  the  same  time,  both 
a cause  and  an  effect  of  the  accident,  and  it  is  difficult  to  decide 
whether  it  be  the  distension  of  the  bladder  that  causes  the  womb  to 
see-saw  backwards  by  raising  its  os  uteri  upwards,  or  whether  the 
gravid  organ,  sinking  by  its  own  weight  or  any  other  cause,  allows  jt 
to  compress  the  neck  of  the  bladder  and  urethra,  and  thus  prevent 
the  escape  of  the  urine. 

When  retroversion  happens  in  a pregnant  woman,  the  orifice  of  the 
urethra  is  retracted  so  much  behind  the  pubis  that  it  becomes  diffi- 
cult to  find  the  meatus,  and  the  urethra  is  so  forcibly  pressed  against 
the  bone  that  it  is  for  the  most  part  impossible  to  pass  up  a catheter, 
even  a flat  one.  The  escape  of  the  urine,  which  now  and  then  takes 
place  by  regorgement,  is,  in  most  cases,  completely  suppressed,  so  that 
the  distension  of  the  badder  may  be  carried  even  to  the  extent  of 
bursting  the  organ,  as  in  the  samples  reported  by  Smellie,  Vandoe- 
veren  and  Syme. 

The  rectum  is  also  so  much  compressed  that  the  smallest  portion 
of  stercora.ceous  matter  cannot  escape  through  the  intestine;  and  the 
patient  is  unable  to  receive  enemata.  Coincidently  with  these  symp- 
toms, there  is  found  a painful  tumefaction  of  the  external  genitals ; 
and  in  performing  the  touch  per  vaginam,  the  womb  is  found,  as  we 
have  already  shown,  higher  up  than  usual ; the  anterior  wall  of  the 
vagina  being  very  tense,  while  the  posterior  one  is  relaxed,  and  even 
puckered.  The  contrary  would  obtain  in  case  of  anteversion. 

The  size  of  the  womb  continuing  to  increase  with  the  progress  of 
the  pregnancy,  the  viscus  is  soon  attacked  with  inflammation : the 
organ  being  now  locked  betwixt  the  sacrum  and  pubis,  is  so  power- 
fully compressed,  in  some  instances,  that  after  death  it  cannot  be 
extricated  without  dividing  the  pubis.  (Levret. ) In  these  dreadful 
cases,  the  inflammation  exteuds  along  the  peritoneum  to  the  bladder 
and  up  to  the  reins,  and  death  has  followed  either  from  these  exten- 
sive inflammations,  or  from  the  rupture  of  the  uterus  itself,  or  the 
giving  way  of  the  bladder.  Yet  the  case  has  been  known  to  have 
a favourable  termination,  even  where  the  patient  has  been  aban- 
doned to  the  powers  of  nature  alone ; the  pain  compelling  the  patient 
to  keep  her  bed,  the  womb  has  reposited  itself,  all  the  symptoms  disap- 
pearing, and  the  pregnancy  has  gone  on  to  its  full  term.  In  some  rare 
instances,  abortion  has  taken  place  after  the  spontaneous  reposition; 
but  it  generally  precedes  the  reposition,  and  allows  it  to  take  place. 

The  augmented  weight  of  the  womb,  and  a certain  relaxation  of 
its  ligaments  being  the  most  ordinary  causes  of  its  vertical  deviations, 
it  would  seem  surprising  that  anteversion  is  not  like  retroversion, 
most  common  in  pregnant  women.  The  explanation  of  the  infre- 
quency of  the  former  and  the  frequency  of  the  latter  or  retroverted 
state,  is  naturally  found  in  the  difference  introduced  by  gestation  into 
the  relation  of  the  parts.  In  fact,  the  posterior  wall  of  the  uterus, 
which,  in  the  non-gravid  state,  is  more  convex  than  the  anterior  one, 


ANTE  VERSION  AND  RETROVERSION. 


159 


really  dilates  in  pregnancy  more  rapidly  than  the  anterior  face,  so  that 
the  fundus  uteri  naturally  tends  to  follow  the  heaviest  portion,  which 
drags  it  downwards,  that  is  to  say,  backwards,  unless  it  is  stopped  by 
impinging  on  the  face  of  the  sacral  curve.  This  is  the  reason  why  one 
of  the  principal  predisposing  causes  is  ja  too  deep  concavity  of  the 
sacrum.  Another  anatomical  arrangement,  which  also  tends  to  pre- 
vent the  occurrence  of  anteversion  in  pregnancy  is,  that  the  auterior 
face  of  the  womb,  as  it  becomes  more  and  more  convex,  encounters 
the  symphysis  pubis,  and  thus  has  a point  d'ctppui , which  tends  to 
repel  the  organ  in  a backward  direction.  It  is  easy  to  understand 
the  mechanism  of  retroversion,  and  the  infrequency  of  anteversion 
during  gestation,  by  reflecting  that,  on  the  one  hand,  the  greater 
weight  of  the  posterior  wall  of  the  womb  draws  the  organ  down 
towards  the  sacrum,  and  that,  on  the  other  hand,  the  retroversion 
takes  place  only  because  the  cavity  of  the  sacrum  is  excessive,  allow- 
ing the  womb  to  be  jammed  into  it,  either  by  a distended  urinary 
bladder,  or  by  the  appui  of  the  os  uteri  against  the  symphysis  of  the 
pubis;  the.  broad  ligaments,  becoming  shorter  and  shorter,  should 
tend  to  hold  up  the  body  of  the  womb  in  the  excavation,  but  the 
sacro-vertebral  angle  hinders  its  rise,  and  compels  the  fundus  to 
incline  backwards,  and  lodge  at  last  in  the  hollow  of  the  sacrum. 

[I  have  met  with  a very  considerable  number  of  cases  of  retroversion  of 
the  womb,  and  though  familiarly  conversant  with  medical  affairs  for  more 
than  thirty  years,  I have  not  been  able  to  meet  with  more  than  one  single 
decided  sample  of  anteversion  of  the  organ.  As  I do  not  altogether  agree 
with  our  author  in  the  views  he  has  presented  us  under  this  head,  I shall 
take  this  opportunity  to  express,  very  briefly,  my  own  opinions  upon  the 
subject. 

I should  judge,  from  the  great  number  of  cases  for  which  I have  been 
consulted — cases  coming  to  me  from  nearly  every  State  in  the  Union — that 
great  suffering  is  by  many  persons  endured,  under  the  idea  that  the  patient 
has  either  a prolapsus,  or  an  irritable  uterus,  or  some  derangement  called 
disorder  of  the  womb,  and  which  is  supposed  to  be  curable  by  rest,  or 
tonics,  or  sea-bathing;  but  which,  in  fact,  can  be  cured  only  by  the  reposi- 
tion of  the  dislocated  organ.  By  inspecting  the  organs  in  situ  naturally  on 
the  anatomical  subject,  it  may  be  clearly  seen  that  the  fundus  uteri  has  a 
very  free  vibration  backwards  and  forwards ; and  that  it  is  only  restrained 
from  falling  quite  down,  backwards,  by  the  ligamenta  rotunda,  which,  coming 
off  from  the  angles  of  the  uterus,  and  being  inserted  on  the  front  of  the  pelvis, 
cannot  permit  a retroversion  to  take  place,  unless  they  are  morbidly  relaxed 
and  extended.  A woman  who  has  a very  large  pelvis,  and  who  allows  her 
bladder  to  become  enormously  distended,  will  be  always  liable  to  retrover- 
sion during  such  distension,  especially  upon  the  occurrence  of  any  sudden 
effort  or  succussion  of  the  abdominal  muscles — as  in  a fit  of  sneezing,  cough- 
ing, or  laughter.  A jump  from  a carriage-step,  or  a chair,  or  a trip  on  the 
pavement,  while  the  womb  is  pushed  backwards  by  the  full  bladder,  may 


160 


ANTEVERSION  AND  RETROVERSION. 


suddenly  and  even  instantly  jam  the  uterus  under  the  promontory  of  the 
sacrum,  which,  introducing  a tenesmic  feeling,  is  followed  by  bearing  down 
efforts,  every  repetition  of  which  aggravates  the  mischief.  If  the  woman 
be  non-gravid,  perhaps  she  will  empty  the  bladder,  and  the  womb,  raised 
upwards  again  by  its  anterior  chords — its  round  ligaments — is  not  suspected 
to  have  been  retroverted  ; but,  if  she  be  pregnant  at  two  and  a half  or  three 
and  a half  months,  and  the  fundus  be  once  jammed  below  the  promontory, 
it  will  probably  remain  there,  even  after  the  bladder  shall  have  been  perfectly 
emptied  by  the  catheter.  I have  seen  it  remain  so  after  the  most  complete 
evacuation  of  the  urinary  bladder,  by  the  catheter.  Let  the  reader  think, 
for  a moment,  that,  when  the  bladder  of  urine  fills,  it  fills  and  distends  back- 
wards, not  upwards;  but  it  cannot  contain  a pint  measure  of  urine  without 
pushing  the  fundus  backwards  ; and  when  the  bladder  can  retreat  no  further 
in  that  direction,  if  the  distension  goes  on,  it  rises  upwards  in  the  belly, 
towards  the  umbilicus,  pushing  the  hvpogaster  outwards,  whose  curve  is 
visibly  augmented  thereby. 

Let  a woman  two  and  a half  months  gone,  get  into  a stage,  or  rail  car, 
having  neglected  to  empty  the  bladder  beforehand  ; if  she  sets  off  on  her 
ride  with  eight  or  twelve  ounces  in  the  organ,  and  is  prevented  for  some 
hours  from  relieving  herself,  she  will  hardly  reach  her  journey’s  end  with- 
out having  retroversion ; and  when  she  attempts  to  relieve  the  bladder,  is 
found  to  labour  under  a total  suppression  of  urine,  or,  at  least,  a most 
painful  dysury.  I have  seen  such  cases. 

A woman  who  has  the  habit  of  permitting  large  accumulations  to  take 
place  in  the  bladder,  can  hardly  fail,  in  the  long  run,  to  relax  and  overstretch 
her  round  ligaments  so  much  as  to  render  them  at  last  useless  to  her.  I am 
acquainted  with  more  than  one  lady,  whose  round  ligaments  are  so  loose  and 
useless,  that  the  womb  falls  over  into  the  hollow  of  the  sacrum,  from  the 
slightest  effort  that  she  makes.  I have  had  to  reposit  it  many  times,  and,  in 
doing  so,  have  found  the  fundus  turned  quite  down  to  the  lower  third  of  the 
sacrum.  I do  not  think  the  weight  of  the  superincumbent  bowels  has,  in 
general,  much,  if  any  thing,  to  do  with  producing  retroversion.  I look  upon 
it  rather  as  a case  of  relaxed  round  ligaments,  and  suppose  that  if  there  were 
any  surgical  means  of  shortening  them,  the  womb,  even  one  qiost  prone  to 
retroversion,  would  thereby  be  deprived  of  the  liability  to  become  retro- 
verted ; unfortunately  we  possess  no  such  means.  There  can  be  little  reason 
to  doubt  of  the  contractility  of  the  round  ligaments  : certainly  they  seem,  in 
some  persons,  to  be  at  one  time  so  relaxed  as  to  allow  the  uterus  to  fall 
backwards  with  the  greatest  facility,  and  then  they  retain  it  for  months  in  its 
natural  situation  ; after  which,  they  again  permit  the  retroversion  to  take  place 
again  and  again ; to  be  succeeded  by  a period  in  which  they  are  strong  enough 
to  prevent  it,  perhaps,  during  the  remainder  of  the  woman’s  lifetime. 

In  retroversion,  the  os  tincae  is  drawn  upwards  behind  and  even  above 
the  lop  of  the  symphysis  pubis.  This  state  of  the  os  uteri  is  attributable 


ANTE  VERSION  AND  RETROVERSION. 


161 


partly  to  the  fact  that  the  fundus,  resting  upon  the  lower  portion  of  the 
sacrum,  compels  the  other  end  of  the  organ  to  rise  into  the  situation  above 
mentioned;  and  this  especially  in  such  as  have  a gravid  or  otherwise 
enlarged  womb.  It  should  be  remembered  here  that  the  pelvis,  measured 
in  an  antero-posterior  direction  from  the  top  of  the  symphysis  to  the  lower 
third  of  the  sacrum,  is  at  least  four  and  a half  inches  in  length,  but  the 
womb  itself  is  not  more  than  three  inches  or  three  and  a half  inches  in 
length*  Hence,  when  the  os  uteri  is  forced  up  in  the  situation  mentioned, 
it  must  be  either  because  the  womb  is  enlarged  by  pregnancy  or  by  disease, 
or  else  because  it  is  strained  upwards  in  that  direction  by  the  contraction  of 
its  overstretched  round  ligaments,  which  are  now  nearly  parallel  with  the  long 
diameter  of  the  organ.  Women,  under  retroversion,  do  certainly  feel  much 
pain  in  the  groins  and  pubis  from  the  strain  on  the  ligamenta  rotunda.  I am 
very  sure  that  a person  in  whom  these  ligaments  are  still  in  a healthful  and 
natural  stale  of  tone  will  be  extremely  unlikely  to  have  a retroverted  womb; 
and  that,  where  the  accident  has  happened,  it  will  be  only  necessary  to  give 
a slight  help  towards  the  reposition  to  make  the  ligaments  draw  the  fundus 
upwards  and  forwards  again,  and  retain  it  in  situ  nalurali  when  once  repo- 
sited. — M.] 

The  mechanism  of  anteversion  of  the  womb  is  extremely  simple, 
and  so  much  the  more  easily  understood  as  the  deviation  is  merely 
an  exaggeration  of  the  natural  inclination  of  the  womb.  As  the 
fundus  uteri  always  inclines  to  the  front  when  the  bladder  is  empty, 
the  slight  anteversion  which  follows  the  evacuation  of  the  bladder  pro- 
duces no  inconvenience,  and  is  not  in  the  least  degree  a morbid  state, 
and  is  promptly  repaired  upon  the  filling  of  the  bladder  again.  Not 
so,  however,  when  the  weight  of  the  womb  is  increased,  in  conse- 
quence of  an  engorgement  of  the  fundus  or  of  its  anterior  wall,  for 
then  the  ligamenta  lata,  being  constantly  stretched,  give  way  by 
degrees,  until  at  length,  whenever  the  woman  stands  up,  the  fundus 
uteri  presses  itself  against  the  bladder,  whose  walls  are  compressed 
together  behind  the  symphysis  pubis,  while  the  os  tincse  is  pointed 
backwards,  and  presses  with  greater  or  less  force  upon  the  rectum. 
This  displacement  is  farther  increased  by  the  weight  of  the  viscera, 
which  always  rest  upon  the  posterior  paries  of  the  womb,  which  now 
ceases  to  have  a vertical,  in  order  to  assume  a horizontal  position  in 
the  pelvis. 

Nevertheless,  anteversion  may,  in  some  instances,  take  place  inde- 
pendently of  any  engorgement  of  the  womb,  for  the  repeated  efforts 
of  a painful  labour,  of  vomiting,  of  constipation,  of  sexual  union 
with  disproportion,  and  in  fine,  great  fatigue  and  violent  shocks,  all 
such  circumstances  have  been  found  to  act  as  occasional  causes.  The 
morbid  adhesions  that  take  place  in  utero-peritoneal  inflammation, 
may  also,  by  the  power  of  their  retraction,  cause  the  womb  to  incline 
forwards,  and  keep  it  immovably  fixed  in  that  position.  The  symp- 
toms already  described,  as  following  in  the  train  of  uterine  displace- 
ments, are  not  sufficient  for  the  establishment  of  a clear  diagnosis, 
11 


162 


ANTE  VERSION  AND  RETROVERSION. 


since  most  of  them  are  common  to  both  the  cases,  i.  e.,  the  antever- 
sion  and  the  retroversion ; and  may,  indeed,  be  met  with  in  some 
cases  of  mere  descent  or  prolapsion  of  the  womb.  It  is  only  by 
Touching  that  we  can  ascertain  both  the  degree  and  the  kind  of  devia- 
tion that  has  taken  place.  If  the  patient  be  placed  in  a standing  posi- 
tion, we  may  discover,  with  the  index,  a sort  of  tumour  just  within  the 
vagina,  that  seems  to  fill  up  the  cavity  of  the  pelvis.  This  tumour 
is  the  womb  itself,  and  it  is  the  anterior  or  posterior  surface  that  we 
touch,  according  to  the  nature  of  the  deviation.  In  anteversion,  we 
touch  the  anterior  face  ; the  fundus  being  diverted  towards  the  sym- 
physis, and  the  os  tineas  to  the  sacrum.  If,  on  the  other  hand,  the  case 
be  one  of  retroversion,  the  womb  presents  its  posterior  surface  to  the 
touch,  the  fundus  resting  upon  the  lower  part  of  the  sacrum,  while 
its  orifice  presses  on  the  pubic  symphysis.  If  we  touch  per  rectum , 
we  encounter  a tumour  composed  of  the  fundus  or  os  uteri  depress- 
ing the  gut.  In  using  the  catheter,  which  it  is  often  difficult  to  do, 
we  discover  against  the  posterior  wall  of  the  bladder  the  solid  and 
fleshy  body,  before  detected  by  means  of  the  fingers,  and  which  gives 
rise  to  a sensation  like  that  occasioned  by  the  touching  of  a scirrhus, 
or  of  an  encysted  calculus  in  the  bladder.  Levret*  confesses  that  he 
mistook  an  anteversion  of  the  womb  for  a case  of  encysted  calculus 
of  the  bladder  ; and  he  did  not  discover  his  error  until  after  he  had 
performed  an  operation  for  lithotomy,  which  was  followed  by  the 
death  of  his  patient,  when,  by  an  examination  of  her  body,  he  found 
that  she  really  had  suffered  from  anteversion  of  the  womb. 

The  position  of  the  os  uteri  in  the  pelvis,  as  being  in  this  or  in  that 
situation,  points  out  the  nature  of  the  existing  displacement,  but  its 
being  at  such  or  such  a height  in  the  excavation  does  not  enable  us 
to  judge  exactly  as  to  its  degree.  In  fact,  we  may,  in  some  cases, 
very  readily  touch  the  os  tincse  with  the  point  of  the  index,  although 
the  retroversion  has  been  carried  to  the  extremest  degree,  because,  as 
Baudelocque  remarks,  the  cervix  uteri  is  liable  to  be  bent  in  certain 
cases  like  the  neck  of  a retort. 

A fibrous  or  an  encysted  tumour,  or  a pregnancy  developed  within 
the  substance  of  the  uterine  paries,  might  be  confounded  with  a dis- 
placement of  the  womb ; but  Touching,  whether  vaginal,  rectal  or 
hypogastric,  ought  to  enable  us  to  decide  upon  the  existence  of  a dou- 
ble tumour  in  the  former  case  or  an  extraordinary  magnitude  of  the 
uterus  in  the  latter.  However,  an  inflammatory  swelling  of  the 
womb  might,  in  some  cases,  lead  us  into  mistakes.  Professor  De- 
sormeauxt  informs  us  that  two  London  physicians  had  mistaken  the 
one  for  a morbid  tumour,  and  the  other  for  a simple  displacement,  a 
retroverted  womb  in  which  the  fundus  was  affected  with  inflamma- 
tory swelling  that  deceived  the  English  practitioners.  Dr.  Demnanf 
also  says  that  a tumour, and  particularly  a serous  cyst  or  an  acephalo- 
cyst,  situated  betwixt  the  vagina  and  rectum, filling  up  the  cavity  of  the 
pelvis,  depressing  the  gut  the  vagina  and  bladder,  may  be  mistaken  for 
retroversion;  but  if  the  tumour  coincides  with  a somewhat  advanced 
stage  of  pregnancy,  it  is  quite  easy  to  eschew  all  mistakes  on  that  point, 

* Journ.  de  Med.,  t.  xl.  p.  269.  -J-  Diet,  de  Med.,  t.  21.  p.  L27. 

\ Introd.  to  the  Pract.  of  Med. 


ANTE  VERSION  AND  RETROVERSION. 


163 


because  we  readily  learn,  by  means  of  the  hypogastric  Touch,  that  the 
womb  contains  the  product  of  a conception  : in  the  non-gravid  state 
the  diagnosis  would  be  more  difficult;  but,  as  has  been  observed  by 
Madame  Boivinand  M.  Duges,  by  touching  the  orifice  of  the  womb, 
we  are  enabled  to  ascertain,  by  its  direction  and  mobility,  the  mutual 
independence  of  the  organ  and  the  tumour,  which,  by  the  way,  is  not 
always  found  upon  the  median  line, and  besides, always  presents  lumps 
and  asperities  that  are  rarely  to  be  found  upon  the  merely  deviated 
womb.  Messrs.  Bellanger  and  Lallemand*  have  related  several  cases 
of  retroversion  that  had  been  mistaken  for  peritoneal  dropsies ; the 
abdominal  distensions  and  fluctuation  having  been  caused  by  the 
accumulation  of  urine  in  the  bladder,  whence  it  escaped  in  but 
very  small  quantities.  By  means  of  the  operation  of  Touching  and 
the  use  of  the  catheter,  it  is  easy  to  dissipate  all  uncertainty  in  such  a 
case,  and  point  out  the  nature  and  situation  of  the  fluid. 

All  other  things  being  equal,  the  symptoms  arising  from  retrover- 
sion are  more  severe  than  those  resulting  from  an  anteversion  ; but  in 
either  case,  the  prognosis  is  so  much  the  more  unfavourable  as  those 
symptoms  are  more  decided  and  of  longer  standing,  and  as  the  womb 
is  more  or  less  closely  compressed  within  the  pelvic  cavity. 

The  treatment  of  anteversion  and  retroversion  offers  for  its  fulfil- 
ment a variety  of  indications,  consisting  not  only  in  the  reposition  of 
the  organ  and  the  maintenance  of  it  in  its  natural  situation,  but  also 
the  removal  of  those  obstacles  that  might  render  useless  every  attempt 
to  reposit  the  womb  ; and  further,  to  remedy  such  accidents  as  may 
have  arisen  from  a prolonged  displacement,  or  from  antecedent 
attempts  at  reduction. 

When  the  case  of  deviation  is  one  of  long  standing  and  considerable 
in  degree,  we  should,  before  proceeding  to  the  reposition,  try  to  remove 
the  inflammatory  symptoms  by  means  of  general  and  local  blood-let- 
ting ; by  baths  and  mucilaginous  injections.  It  has  often  happened  that 
the  judicious  employment  of  antiphlogistics  has  made  it  possible  to 
effect  a reduction,  in  which  all  preceding  attempts  had  proved  so  una- 
vailing as  to  lead  to  the  conclusion  that  reduction  was  impracticable.  As 
the  alvine  and  urinary  discharges  are  always  more  or  less  obstructed, 
attention  should  invariably  be  paid  to  the  re-establishment  of  a free 
course  to  both  these  evacuations,  with  a view  to  remove,  as  far  as  pos- 
sible, every  obstacle  to  the  rise  of  the  womb.  The  use  of  the  catheter 
and  the  evacuation  of  the  rectum,  or  the  discharge  of  the  urine  by  Bau- 
delocque’s  method,  which  consists  in  raising  up  the  os  uteri,  have,  in 
many  cases,  been  sufficent  to  allow  the  organ  to  resume  its  natural 
position.  Where  the  retraction  of  the  meatus  urinae  upwards  and 
backwards,  and  the  flattening  of  the  urethra  should  happen  to  render 
the  introduction  of  the  catheter  difficult,  recourse  ought  to  be  had 
to  Segrot’s  flat  catheter,  which  may  be  introduced  by  turning  its  con- 
cavity backwards,  and  at  the  same  time  taking  care  to  push  away 
the  os  uteri  where  it  compresses  the  canal  of  the  urethra,  which  may 
be  done  by  passing  the  finger  upwards  betwixt  the  symphysis  pubis 
and  the  womb. 


* Revue  Med.,  t.  i.  p.  191,  arm.  1824. 


164 


ANTE  VERSION  AND  RETROVERSION. 


Alarmed  at  the  difficulties  experienced  in  introducing  the  catheter 
in  certain  cases,  both  Syme  and  Dussaussoy  advise  that  the  bladder 
should  be  punctured  below  the  pubis,  and  Sabatier  himself  has  laid  it 
down  as  a formal  precept  for  cases  where  the  catheter  cannot  be 
applied.  After  the  bladder  is  emptied  by  either  of  the  methods  now 
mentioned,  rest  and  suitable  posture  may  suffice  to  enable  the  reduc- 
tion to  take  place  spontaneously,  especially  if  the  rectum  have  been 
emptied  by  means  of  enemata,  which,  unfortunately,  can  be  done 
only  in  a few  cases. 

To  reduce  the  womb,  the  patient  should  be  placed  in  a proper 
position; — she  ought  to  lie  upon  the  back  in  such  manner  as  to  allow 
the  muscles  of  the  belly  to  be  as  much  relaxed  as  possible;  upon 
which,  an  attempt  ought  to  be  made  to  restore  the  organ  to  its  position 
by  drawing  upon  the  os  tincae  with  the  finger  bent  into  a hook  shape, 
wheiher  it  be  turned  towards  the  sacrum  or  above  the  top  of  the  sym- 
physis pubis.  Should  this  measure  fail  of  success,  let  two  fingers  of 
the  left  hand  be  carried  into  the  rectum  in  order  to  push  up  the  fun- 
dus with  them,  while  with  one  or  two  fingers  of  the  other  hand 
passed  into  the  vagina,  we  try  to  pull  the  cervix  downwards.  In  case 
we  cannot  reach  the  os  tincae  we  should  endeavour  to  draw  it  down 
with  the  spoon-shaped  instrument  of  Mad.  Boivin,  or  with  the  one 
which  we  designed  for  the  same  purpose,  and  which  we  think  more 
convenient.  — ( Vide  fig.  8,  p.  68.)  Should  all  these  attempts  fail  of 
the  desired  success,  let  the  woman  place  herself  upon  her  knees  and 
elbows,  because,  in  this  situation,  the  abdominal  viscera  press  with 
less  force  upon  the  rectum,  and  by  their  own  displacement,  favour 
the  rise  of  the  womb,  while  the  surgeon  endeavours  to  unlock.and 
disengage  it  from  the  cavity  of  the  pelvis. 

Should  all  these  means  prove  ineffectual,  we  might  follow  the  plan 
of  Dussaussoy,  formerly  chirurgien-major  of  the  Hotel  Dieu,  at  Lyons, 
which  was  to  introduce  the  whole  hand  into  the  rectum*  and  then 
push  up  the  body  of  the  womb,  which  would  more  readily  yield  to 
this  attempt,  if  assisted  by  a couple  of  the  fingers  within  the  vagina, 
and  acting  simultaneously  upon  the  cervix.  Should  the  fingers  not 
find  a sufficient  hold,  the  surgeon  ought  to  pass  into  the  bladder  a 
strong  catheter,  flattened  at  its  vesical  extremity,  to  be  made  use  of  as 
a lever  to  depress  the  os  uteri,  by  acting  on  it  from  the  interior  of  the 
bladder,  while  the  fingers,  introduced  at  the  same  time  into  the  rec- 
tum, aid  in  elevating  the  fundus  uteri.  This  is  the  plan  adopted  by 
Messrs.  Bellanger  and  Lallemand.  It  has  often  happened  that,  in 
cases  where  all  other  means  have  failed,  the  womb  has  been  disen- 
gaged by  the  see-saw  movement  effected  as  above  described.  It 
ought  to  be  observed  that,  for  the  most  part,  the  first  attempt,  par- 

* A measure  that  assists  considerably  in  the  dilatation  of  the  rectum,  consists  in 
introducing  into  the  bowel,  several  times  before  the  commencement  of  the  attempt, 
a suppository  of  beurre  de  cacao , either  simple  or  combined  with  extract  of  bel- 
ladonna, in  the  proportion  of  one  grain  of  the  latter  to  twenty  of  the  former.  The  use 
of  this  means,  which  is  also  very  efficacious  as  a remedy  for  constipation,  produced 
by  constriction  of  the  sphincter,  facilitates  the  introduction  of  the  fingers  and  the 
enlargement  of  the  anus,  while  it  lessens  the  pain  arising  from  the  distension  of  the 
bowel. 


ANTE  VERSION  AND  RETROVERSION. 


165 


ticularly  in  the  case  of  ante  version,  succeeds  in  restoring  the  womb  to 
its  natural  position. 

[In  certain  cases  of  extreme  difficulty  encountered  in  the  attempt  to  reduce 
the  retroverted  womb  while  the  patient  was  lying  upon  the  side  or  the  back, 
I have  readily  effected  the  reposition,  upon  directing  the  woman  to  place  her- 
self upon  her  knees,  with  the  thighs  at  right  angles  to  the  bed  and  perfectly 
vertical,  while  the  top  of  the  thorax,  or  rather  the  sternum,  should  be  in  contact 
with  the  mattress.  In  such  a position,  not  only  is  the  weight  of  the  viscera 
taken  off,  but  what  is  of  greater  consequence,  the  power  of  tenesmic  resistance 
is  wholly  abolished,  while  the  position  favours,  in  the  highest  degree,  the 
reposition  of  the  womb.  In  this  posture  the  woman  cannot  bear  down.  I 
consider  such  a position  as  favouring  the  reduction  in  a degree  far  greater  than 
the  large  bleedings  recommended  by  Dr.  Dewees,  who  bled  ad  deliquium  for 
the  purpose  of  abolishing  the  tenesmic  power,  or  the  power  to  bear  down, 
which  he  considered  as  one  of  the  chief  obstacles  to  success.  In  such  a posi- 
tion the  surgeon  can  hardly  fail  of  success,  except  in  cases  where  reduction 
is  rendered  impossible  from  adhesions  contracted  in  consequence  of  a long 
chronic  state  of  retroversion — such  cases  are  to  be  held  as  incurable. — M.l 

Where  the  reposition  has  been  effected  and  the  womb  is  non-gravid, 
all  that  is  necessary  to  prevent  a relapse,  is  to  make  the  woman  keep 
herself  in  a horizontal  posture  for  several  months,  to  be  followed  by 
river  or  sea-bathing  and  the  use  of  ascending  douches,  composed  of 
tonic  decoctions,  and  especially  of  the  sulphurous  waters  of  Bareges. 
If  the  disorder  were  of  a very  ancient  date,  and  should  have  reached 
a certain  stage,  all  these  means  might  be  unavailing,  and  we  should 
be  compelled  to  have  recourse  to  pessaries,  especially  the  pessary  en 
bilboquet , which,  receiving  the  os  uteri  within  the  cupel,  might  lix  it 
in  the  centre  of  the  pelvic  excavation,  and  compel  the  fundus  to 
remain  in  its  natural  situation.  Bilboquet  pessaries,  when  well  ad- 
justed by  their  stems,  by  means  of  a girdle  and  straps,  are  least  apt 
to  be  displaced,  and  are  more  sure  to  prevent  a retroversion  than 
any  other  pessary,  which,  for  the  most  part,  repel  the  whole  organ, 
and  keep  it  up,  but  do  not  so  well  keep  it  in  its  natural  attitude. 

Instead  of  placing  a pessary  in  the  vagina,  Aspasia  (Aetius,  loc. 
ci tat .,)  proceeded  to  the  treatment  of  retroversion  in  the  following 
manner  ( at  vero , aversionem  versus  anam  ita  curabimus) : She 
advised  the  midwife  (obstelrix)  to  introduce  a finger  into  the  rectum 
and  push  the  womb  forwards.  She  next  introduced  permanently 
into  the  rectum  a large  bougie,  (g tandem ,)  of  the  length  of  four 
inches,  to  the  end  of  which  a string  was  attached  for  the  purpose  of 
extracting  it  readily.  She  then  ordered  oily  injections  for  both  the 
rectum  and  vagina.  For  the  fulfilment  of  the  indication  laid  down 
by  Aspasia,  i.  e.,  to  keep  the  womb  reposited,  use  has  been  made  of 
sponges,  either  alone  or  attached  to  straight  or  curved  stems,  and 
placed  in  the  gut,  or  in  the  vagina,  as  well  as  other  means  mostly 
inefficacious.  Professor  Desormeaux,  with  a view  to  attain  the  same 
end  more  simply  and  certainly,  proposed  the  introduction  of  a ring- 


166 


ANTE  VERSION  AND  RETROVERSION. 


pessary  of  caoutchouc  to  be  placed  behind  the  cervix  uteri ; but  this 
plan  has  been  used  in  vain  by  several  practitioners,  and,  among 
others,  by  M.  Nauche.  The  vagina-shaped  pessary,  denominated  by 
M.  Cloquet  the  elytroid  pessary,  or  Rognetta’s 
cylindrical  one;— either  of  them,  if  provided 
with  a cup-shaped  end,  cut  sloping,  like  the 
one  represented  in  our  figure,  appears  to  us 
best  calculated  to  keep  the  womb  in  its  natural 
position.  If  the  case  be  one  of  anteversion, 
the  salient  edge  of  the  cup  should  be  placed 
betwixt  the  sacrum  and  the  cervix ; whereas, 
it  ought  to  be  placed  betwixt  the  cervix  and 
the  posterior  surface  of  the  pubis,  if  the  case 
be  one  of  retroversion.  The  absence  of  the 
wall  and  edge  of  the  cup  upon  one  side  of  the 
instrument  would  admit  of  the  uterus  being  pushed  in  a direction 
opposite  to  that  in  which  the  deviation  might  have  taken  place,  with 
greater  effect  than  could  be  produced  by  a pessary  with  a cup  of  the 
ordinary  form,  where  an  unbroken  edge  would  not  allow  of  so  com- 
plete a reposition. 

When  anteversion  takes  place  in  consequence  of  inflammation 
and  engorgement  of  the  womb,  great  care  should  be  taken  in  regard 
to  the  use  of  the  pessary,  inasmuch  as  its  presence  in  the  vagina, 
and  immediate  contact  with  the  inflamed  organ,  might  increase  the 
irritation,  and,  consequently,  the  essential  cause  of  the  deviation. 
Under  such  circumstances,  recourse  ought  to  be  had  to  antiphlogistic 
remedies — to  small  revulsive  bleedings,  to  emollients  in  the  form  of 
baths,  drinks,  injections,  cataplasms,  and  fomentations.  These  reme- 
dies persevered  in  for  some  weeks,  and  conjoined  with  the  employ- 
ment of  narcotics,  and  a dorsal  decubitus,  upon  a bed  so  arranged  as  to 
allow  the  hips  to  be  raised  somewhat  higher  than  the  trunk,  are 
means  that  have  often  succeeded  in  obtaining  a complete  cure.  The 
reposition,  by  means  of  a pessary,  should,  on  the  other  hand,  always 
be  preferred  where  the  sensibility  of  the  parts  is  not  too  acute.  It 
has  often  happened  that  the  mechanical  irritation  produced  by  the 
instrument,  has  caused  the  total  dissipation  of  a chronic  metritis, 
which  had  been  either  the  cause  or  the  effect  of  the  displacement. 
Levret  thinks  that  the  employment  of  the  pessary  is  generally  suffi- 
cient for  the  cure  of  an  anteversion,  but  the  instrument  should  be 
worn  from  ten  to  fifteen  months ; he  adds  that  the  leucorrhoeal  dis- 
charge, which  is  at  first  provoked  by  its  presence,  soon  grows  less, 
and  at  length  disappears  altogether,  which  is  a sign  of  the  cure. 
Desormeaux,  who  adopted  Levret’s  views  upon  this  point,  was  of 
opinion  that  the  pessary  is  not  required  for  so  long  a time,  and  that 
the  vaginal  inflammation  resulting  from  its  presence  would  deter- 
mine a secretion  favourable  to  the  disengorgement  of  the  womb,  by 
acting  on  the  principle  of  a derivative  remedy.  One  thing  is  certain, 
that  even  if  the  pessary  is  incapable  of  effecting  a perfect  cure,  it  at 
least  has  the  merit  of  procuring  great  relief  in  the  displacements  under 
consideration. 


Fig.  19. 


ANTE  VERSION  AND  RETROVERSION. 


167 


Where  the  displacement  is  a retroversion,  prolonged  to  the  third 
or  fourth  month  of  pregnancy,  the  womb  is  sometimes  found  to  be 
so  completely  locked  betwixt  the  sacrum  and  pubis,  that  its  reduction 
is  impossible,  and  the  woman  becomes  exposed  to  the  danger  of  cer- 
tain death,  if  she  be  not  artificially  relieved.  In  this  frightful  situa- 
tion, when  both  the  mother  and  child  are  devoted  to  inevitable 
destruction,  there  remains  a last  extreme  resource,  first  proposed  by 
Syme  and  recommended  by  blunter.*  This  last  hope  of  safety, 
which,  after  it  is  resorted  to,  may  admit  of  the  reposition  of  the  womb, 
consists  in  plunging  a trocar  into  the  viscus,  through  the  vagina,  so 
as  to  discharge  the  waters  of  the  ovum,  which  are  of  very  great 
volume  at  that  stage,  in  comparison  with  the  size  of  the  foetus.  This 
operation,  in  the  cases  by  M.  Jourel  of  Rouen,  M.  Viricel  of  Lyons, 
and  more  recently  by  Mr.  Baynham,  under  circumstances  that  ap- 
peared to  leave  no  hope  of  saving  the  patients,  was  followed  by 
diminution  of  the  symptoms,  brought  on  abortion,  and  preserved 
the  lives  of  the  mothers.  Having  ascertained  the  necessity  for  re- 
sorting to  this  extreme  method,  which  yet  offers  considerable  chances 
of  safety,  it  should  be  undertaken  in  the  following  manner  : The 
woman  being  properly  placed,  and  supported  by  assistants,  the  ope- 
rator should  endeavour  to  ascertain  whether  the  womb  is  most  tense 
towards  the  vagina  or  the  rectum  ; and  then,  before  he  plunges  the 
trocar  into  the  womb,  he  should  use  all  proper  means  to  reach  the 
cavity  of  the  organ  through  the  os  tincse,so  as  to  open  the  membranes 
of  the  ovum,  as  advised  by  White,  Hamilton,  Dewees  and  Jourel; 
but  attempted  by  them  in  vain.  To  facilitate  this  perforation,  use 
might  be  made,  as  Duges  advises,  of  a male  catheter,  of  a conical 
shape,  and  properly  curved,  so  as  to  enter  the  os  uteri  readily : or  a 
gum  elastic  catheter  might  be  preferred,  the  flexibility  of  which 
would  favour  its  introduction,  as  it  would  adapt  itself  to  all  the  curves 
and  turns  that  might  coexist  with  the  unnatural  situation  of  the 
parts.  When  the  catheter  shall  have  been  penetrated  into  the  cavity 
of  the  womb,  a flexible  style  should  be  passed  up  through  it,  and 
thus  easily  conducted  into  the  uterine  cavity ; and  being  pushed  for- 
wards, might  serve  to  open  the  membranes. 

Should  the  surgeon  be  unable  to  effect  this  purpose,  the  puncture 
should  be  made  by  a trocar  passed  through  the  substance  of  the 
vagina  and  one  of  the  surfaces  of  the  cervix  or  body  of  the  uterus  ; 
for  the  operation  done  in  this  way  is  easier  and  less  dangerous  than 
where  it  is  done  through  the  rectum,  since,  by  the  latter  mode,  it  is 
impossible  to  avoid  wounding  the  peritoneum.  Nevertheless,  the 
puncture  of  the  womb  from  the  rectum  succeeded  in  Mr.  Baynham’s 
case,  after  he  had  in  vain  introduced  his  hand  into  the  bowel,  with 
a view  to  push  the  womb  upwards.  The  woman  operated  on  by 
this  able  practitioner  was  in  the  sixth  month  of  pregnancy,  and  the 
retroversion  had  existed  for  five  weeks.  The  puncture  having 
lessened  the  volume  of  the  womb,  the  reposition  was  easily  effected, 
and  abortion  followed  soon  afterwards.  The  foetus,  which  had  a 
wound  in  the  abdomen,  was  of  the  ordinary  size  of  the  foetus  at  the 

* Med.  Obs.  and  Inq.,  v.  iv. 


168 


ANTE  VERSION  AND  RETROVERSION. 


sixth  month.  In  six  weeks  the  woman  was  quite  recovered.  Baron 
Boyer  [Mai.  Chirurg.,  t.  x.  p.  534),  cites  another  case,  treated  suc- 
cessfully by  the  same  method,  and  mentioned  in  the  Reciteil  des  The- 
ses de  la  Faculle  de  Paris. 

For  making  the  puncture  by  the  rectum,  the  common  trocar  is  too 
short.  It  is  better  to  use  Fleur  ant’s  trocar,  designed  for  puncturing 
the  bladder  from  the  anus,  the  curved  canula  of  which  is  about  an 
inch  longer  than  the  common  ones,  which  facilitates  the  operation 
very  much.  But  whatsoever  be  the  method  adopted,  the  perforator 
should  be  carried  pretty  deep  into  the  womb.  There  should  be  pro- 
vided a long  probe-pointed  stilet,  for  the  purpose  of  clearing  the 
canula,  in  case  of  its  becoming  obstructed  so  as  to  prevent  the  escape 
of  the  amniotic  fluid.  After  the  operation  is  completed,  we  should 
proceed  to  reduce  the  womb  to  its  natural  position  ; and  afterwards, 
bestow  upon  the  patient  all  the  cares  required  in  cases  of  forced 
abortion,  which  is  an  almost  inevitable  result  of  the  puncture  of  the 
womb. 

With  a view  to  unlock  the  womb,  when  imprisoned  in  the  pelvis 
by  retroversion,  and  to  save  the  child  without  exposing  the  mother’s 
life  to  any  greater  risk,  different  practitioners,  among  whom  we  may 
name  Purcell,  Gardien,  Baumgarten  and  Jahn,  propose,  instead  of 
the  puncture,  to  perform  the  operation  for  the  section  of  the  symphy- 
sis ; this  procedure,  which  has  never  yet  been  had  recourse  to,  for  the 
cure  of  uterine  displacement,  even  leaving  out  of  question  its  danger- 
ous nature  and  other  inconveniences,  does  not  seem  to  possess  the 
advantages  attributed  to  it  by  its  friends,  for  the  slight  increase  in  the 
transverse  diameter  of  the  pelvis,  procured  by  the  section,  gives  very 
little  addition  to  the  antero-posterior  diameter,  which  is  the  one  most 
concerned  in  the  locking  of  the  womb.  It  is  also  our  opinion,  that,  as 
we  have  it  in  our  power  to  puncture  either  the  womb  or  the  bladder, 
we  have  no  right  to  recur  to  the  hypogastric  incision  that  has  been 
proposed,  with  a view  of  getting  the  hand  into  the  pelvic  cavity,  for 
the  purpose  of  raising  up  the  uterus.  This  mode  of  proceeding, 
which  is,  however,  less  cruel  than  the  Caesarian  operation,  seems  to 
us  of  very  doubtful  utility,  for  in  the  post-mortem  examination  of  a 
woman  who  perished  from  retroversion,  Hunter  was  unable  to  extri- 
cate the  womb  until  he  had  sawed  the  pelvis  asunder. 

Before  concluding  the  observations  we  had  to  offer  upon  the  sub- 
ject of  the  deviations  of  the  womb,  we  add  that,  where,  by  the  use 
of  the  measures  above  pointed  out,  we  have  succeeded  in  repositing 
the  displaced  organ,  we  should  advise  the  woman  always  to  evacuate 
the  bladder  at  the  first  indication  of  desire  to  do  so  ; and  to  take 
great  care  to  obviate  constipation  of  the  bowels,  especially  by  means 
of  a suppository  composed  of  the  beurre  de  cacao. 

The  inflammatory  sequela?  may  be  counteracted  by  the  use  of  baths, 
venesection,  and  the  other  antiphlogistics  already  pointed  out.  The 
same  kind  of  measures  should  be  resorted  to  in  case  of  the  occurrence 
of  suppression  of  urine,  dependent  upon  inflammation  from  the  pres- 
sure of  the  neck  of  the  womb  upon  the  neck  of  the  bladder.  Where 
the  suppression  of  urine  arises  from  a state  of  inertia,  produced  by 


CURVATURE  OF  THE  WOMB. 


169 


the  prolonged  distension  of  the  cyst,  an  attempt  to  restore  its  tone 
might  be  made  by  means  of  aromatic  and  astringent  injections,  and 
more  especially,  by  injections  of  the  sulphurous  Barege  water.  The 
same  indication  would  exist  in  case  of  an  ischuria  or  dysury  from 
paralysis  of  the  sphincter-vesicse  ; an  accident  that  sometimes  follows 
the  compression  exerted  by  the  os  tincae  upon  the  bladder  during  a 
retroversion. 

OF  THE  ANTEFLEXION  AND  RETROFLEXION  OR  CURVATURE  OF 

THE  UTERUS. 

Although  we  might  as  well  have  classed  the  anteflexion  and  retro- 
flexion of  the  womb  among  the  cases  of  lesion  of  form , as  among 
those  of  lesion  of  situation,  we  have  chosen  to  arrange  them  among 
cases  of  the  last-named  lesion,  in  order  to  make  the  study  of  them 
easier,  by  approximating  them  to  the  cases  of  anteversion  and  retro- 
version, from  which  they  differ  very  little,  either  as  regards  the  treat- 
ment, or  in  the  general  symptoms  pertaining  to  them. 

Though  the  curvature , or  flexions  of  the  womb,  have  hitherto 
attracted  but  little  attention  from  either  writers  or  practitioners,  it 
was  not  because  such  cases  were  rarely  met  with,  but  because  they 
were  most  generally  confounded  with  other  uterine  disorders. 

Notwithstanding  that  Levret,  towards  the  middle  of  the  last  cen- 
tury, and  Baudelocque,  a few  years  later,  had  noticed  that  in  a cer- 
tain malposition  of  the  womb,  the  neck  inclined  to  the  same  side  as 
the  fundus,  while  the  body  of  the  organ  is  bent  like  a retort,  we  are 
indebted  to  Denman*  for  the  first  accurate  account  of  a case  of 
flexion  of  the  womb,  which  was  published,  however,  without  any 
circumstantial  details.  Nevertheless,  Denman’s  case,  and  the  re- 
marks made  before  his  time  by  Levret  and  Baudelocque,  had  been 
almost  forgotten,  when  a new  case,  communicated  by  Madame 
Boivin  to  Dr.  Ameline,  and  inserted  in  his  Thesis,!  fixed  the  atten- 
tion of  the  learned  upon  the  curvatures  of  the  uterus,  disorders  which, 
since  that  date,  have  been  several  times  ascertained  and  rationally 
treated  by  different  medical  practitioners,  among  whom  may  be  men- 
tioned Desormeaux,  Duges  and  Deneux. 

Where  the  flexion  of  the  womb  is  an  anteflexion,  the  neck  pre- 
serves its  natural  position,  but  the  body  of  the  organ  is  inclined  for- 
wards, and  engaged  behind  the  symphysis  of  the  pubis.  In  retro- 
flexion, the  viscus  is  displaced  in  the  inverse  direction  ; that  is,  the 
fundus  is  turned  backwards  and  engaged  in  the  hollow  of  the  sacrum, 
notwithstanding  the  neck,  as  in  the  former  case,  preserves  its  natural 
direction. 

The  curvatures  of  the  womb  do  not  always  exhibit  the  disposition 
of  parts  just  mentioned,  for  some  cases  are  met  with  where  the  body 
and  neck  are  directed  to  the  same  point,  or  these  parts  are  alone  found 
to  deviate,  while  the  fundus  preserves  its  natural  situation.  As  this 
sort  of  flexion,  so  much  insisted  on  by  Boer,  is  almost  always,  when 


* Introduction.  1801. 
t Dissert.  Inaug.  Paris,  1827.  No.  55. 


170 


CURVATURE  OF  THE  WOMB. 


noticed,  coincident  with  the  gravid  state,  we  shall  merely  point  it  out 
at  present,  preferring  to  go  more  in  extenso  into  the  description  of 
those  flexions  that  are  met  with  in  the  non-gravid  state. 

According  to  M.  Duges,  flexions  of  the  womb  may  be  congenital; 
at  least  that  distinguished  practitioner  met  with  it  in  girls  who  had 
not  yet  attained  the  age  of  puberty.  Cases  of  the  kind  must  be  very 
rare.  Yet  we  agree  with  Duges  and  Madame  Boivin,  that  the  rapid 
development  of  the  womb  that  occurs  at  about  the  twelfth  year  of 
the  girl’s  age,  may  sufficiently  explain  how,  in  other  cases,  a more 
complete  development  of  one  wall  of  the  organ  may  lead  to  a sort  of 
organic  incurvation.  The  more  rapid  reduction,  and  more  complete 
condensation  of  one  of  the  walls  of  the  womb,  after  lying-in ; the 
softening  or  retraction  of  one  side  of  the  organ,  from  the  healing  of 
an  internal  ulcer,  or  the  cure  of  an  inflammation;  the  fibrous  dege- 
nerations ; the  adhesion  of  one  of  the  parietes  with  the  uterine  ap- 
pendages; an  obstruction  of  the  canal  of  the  neck,  and,  according  to 
Denman,  a retention  of  urine,  following  childbirth,  may  act  as  essen- 
tial causes  of  flexion  of  the  womb,  and  particularly  of  retroflexion. 
We  however  believe,  with  the  able  Montpellier  professor,  that  the 
last-named  circumstance  cannot  give  rise  to  a uterine  flexion,  unless 
connected  with  one  of  the  special  positions  we  have  mentioned. 

The  incurvation  that  takes  place  at  the  point  where  the  upper  part 
of  the  neck  unites  with  the  body  of  the  womb,  exhibits  a variable 
curvature,  so  that  the  organ  which  is,  in  some  cases,  bent  double,  as  it 
were,  is  found  in  others  to  exhibit  an  angle  more  or  less  obtuse.  The 
curvature  is  always  somewhat  rigid ; and  in  rare  cases,  especially 
soon  after  delivery,  the  body  of  the  womb  is  observed  to  be  movable 
upon  the  neck,  as  pointed  out  in  the  case  of  retroflexion  published 
by  Denman. 

The  general  signs  of  anteflexion  and  retroflexion  are  nearly  the 
same  as  those  of  anteversion  and  retroversion ; for  example,  the  pa- 
tient complains  of  pain  in  the  lumbar  and  hypogastric  regions,  diffi- 
culty in  the  expulsion  of  urine  and  stool,  and  all  the  consecutive 
sympathetic  affections  appropriate  to  the  other  forms  of  uterine  de- 
viations ; such  as  leucorrhaea,  amenorrhcea,  dysmenorrhoea,  hysteri- 
cal and  spasmodic  symptoms ; dragging  sensations  in  the  pelvis,  the 
groin,  the  loins  and  the  thighs  ; frequent  desire  to  pass  the  urine  ; and 
lastly,  a feeling  of  painful  pressure  upon  the  bladder  and  rectum,  &c. 

Although  it  is  very  difficult  clearly  to  establish  the  differences  be- 
tween the  curvatures  of  the  womb  and  anteversion  and  retroversion 
of  the  organ,  it  is  yet  possible,  with  an  attentive  exploration  of  the 
parts,  to  avoid  confounding  them  with  each  other. 

Previously  to  making  any  examination  whatever,  it  is  best  to  cause 
the  bladder  and  rectum  to  be  freed  from  their  contents.  The  surgeon 
should  then  perform  the  operation  of  Touching ; first,  while  the  wo- 
man is  iu  a standing  posture,  and  then  while  she  is  lying  down ; in 
the  same  position  as  if  she  were  placed  for  the  adjustment  of  the 
speculum  uteri.  The  right  index  should  be  placed  within  the  vagina, 
while  the  left  hand  is  applied  to  the  hypogastriuni  for  the  purpose  of 
rendering,  by  pressure  downwards,  the  body  and  cervix  of  the  womb 


CURVATURE  OF  THE  WOMB. 


171 


more  accessible  to  the  point  of  the  index.  The  surgeon  will  endea- 
vour, by  gentle  pressure,  to  learn  whether  the  fundus  of  the  organ  is 
in  its  natural  state  or  not  while  the  neck  only  is  bent ; or  whether 
the  latter  is  in  a natural  position,  the  former  alone  having  deviated 
from  it.  The  latter  sort  of  flexion  is  much  more  common  than  the 
former,  which  is  less  rare  than  the  double  flexion  of  the  cervix  and 
fundus  in  the  same  direction. 

To  enable  us  to  judge  methodically  of  the  size  of  the  curve  formed 
by  the  womb,  the  viscus  ought  to  be  firmly  compressed  by  the  left 
hand  applied  to  the  hypogastrium,  while,  with  the  index  of  the  right 
hand,  we  endeavour  carefully  to  trace  the  arc  described  by  the  flex- 
ion of  the  uterus,  tracing  the  left  side  of  it  with  the  right  index,  and 
the  right  side  of  it  with  the  left  index  finger,  according  as  we  use 
one  or  the  other  hand  for  the  purpose. 

To  render  the  diagnosis  as  complete  as  possible,  and  make  sure  whe- 
ther or  no  there  have  been  formed  any  adhesions  rendering  a cure  im- 
possible, we  should  try  to  move  the  womb  in  different  directions,  and 
if  any  doubt  or  obscurity* should  still  remain  upon  this  or  any  other 
point,  an  examination  by  the  rectum  should  be  made  ; either  in  the 
common  mode,  or  as  advised  by  M.  Duges — by  introducing  the  index 
into  the  rectum,  and  the  thumb  into  the  vagina,  so  as  to  support  the 
womb  between  the  thumb  and  the  finger,  and  thus  form  a sort  of 
intelligent  calliper  well  suited  to  show  the  curvature,  the  size  and 
position  of  the  organ.  This  manoeuvre  is  generally  very  easily  per- 
formed for  women  who  are  thin,  and  accustomed  lo  the  coitus;  and 
in  lymphatic  girls,  whose  vaginal  parietes  have  become  relaxed  by 
chronic  leucorrhcea. 

While  sterility  may,  on  the  one  hand,  depend  upon  a uterine  cur- 
vature, so  a pregnancy,  on  the  other  hand,  may  bring  about  a speedy 
and  definitive  cure  ; for  the  forced  distension  of  the  strangulated  point 
that  divides  the  cervix  and  the  body  of  the  uterus,  will  sometimes 
rectify  its  direction,  where  care  is  taken  in  the  early  months  of  ges- 
tation to  keep  it  in  a proper  position  ; and,  especially,  by  guarding 
against  the  accidents  that  act  as  the  special  causes  of  uterine  displace- 
ments. To  prevent  a relapse,  as  soon  as  the  delivery  is  completed, 
we  should  hasten  to  procure  a perfect  contraction  of  the  womb,  now 
restored  to  its  natural  situation,  by  means  of  frictions  upon  the  hy- 
pogastrium, and  by  preventing  too  great  an  accumulation  of  urine  in 
the  bladder,  or  of  fesces  in  the  rectum.  A relapse  may  also  be  pre- 
vented by  ordering  a dorsal  decubitus,  in  case  it  be  an  anteflexion  ; 
and  by  directing  the  patient  to  lie  upon  her  side,  or  as  far  over  into 
a prone  position  as  possible,  in  case  we  have  to  contend  with  the 
retroflectLve  curvature.  But  whatever  be  the  nature  of  the  curve,  the 
woman  should  be  so  situated  upon  her  bed  as  to  have  the  pelvis 
higher  than  the  shoulders. 

The  treatment  of  flexions  of  the  womb  differs  very  little  from 
that  of  the  anteversion  and  retroversion  of  the  viscus ; for  the  symp- 
toms arising  from  them  are  to  be  combated  by  the  same  general 
measures.  Thus,  where  there  are  symptoms  of  congestion,  of  ple- 
thora, or  of  phlogosis,  resort  should  be  had,  in  the  first  place,  to 


172 


INCLINATION,  OR  OBLIQUITY  OF  THE  WOMB. 


baths,  to  blood-letting,  and  to  other  antiphlogistics,  according  to  the 
kind  of  indication ; and  then,  after  effecting  the  mechanical  reduction 
of  the  womb,  it  is  to  be  kept  in  its  proper  position,  either  by  M. 
Dereux’s  method,  which  consists  in  pressing  a sponge  betwixt  the 
cervix  and  vagina,  opposite  to  the  curve  ; or  in  adjusting,  in  the 
same  situation,  a ring-pessary  of  gum-elastic  or  ivory,  which  is  to  be 
merely  introduced  ; or,  according  to  Desormeaux’s  advice,  to  be  so 
adjusted  that  the  upper  portion  of  the  instrument  should  sustain  the 
raised  fundus,  while  the  opening  is  large  enough  to  receive  the  curved 
extremity  of  the  neck  of  the  womb.  We  might  also  do  as  advised 
by  M.  Nauche  ; namely,  make  use  of  a pessary  en  bondon , so  con- 
structed that  one  of  its  margins  may  rise  highest  on  the  curved  side. 
The  application  of  a cylindrical  pessary,  modified  according  to  our 
plan,  as  a remedy  for  both  anteversion  and  retroversion,  would  fulfil 
this  indication  still  better;  but,  unfortunately,  curvatures  of  ancient 
date  are  very  difficult  to  cure  by  means  of  the  mechanical  remedies 
within  our  control. 

The  symptoms  produced  by  uterine  curvatures  might  also  be  ad- 
vantageously combated,  and  the  powers  of  the  other  remedies  in- 
creased by  assisting  them  by  the  exhibition  of  stimulants,  derivatives 
and  tonics,  such  as  douches  of  Bareges  waters,  directed  into  the 
vagina  and  rectum ; frictions,  blisters,  cauteries,  and  moxas  ap- 
plied, in  the  cases  of  retroflexion,  to  the  groins  and  pubis;  and,  in 
those  of  anteflexion,  to  the  sacrum  and  the  parts  adjacent  to  the 
utero-sacral  ligaments. 

Let  us  conclude  our  remarks  upon  the  uterine  curvatures  by 
adding,  that  Madame  Boivin  and  M.  Duges  are  the  only  authors 
who  have  furnished  detailed  cases  of  anteflexion  and  retroflexion, 
either  in  the  virgin  or  in  women  at  various  stages  of  gestation,  after 
childbirth,  or  as  one  of  the  sequelae  of  abortion.  Were  it  not  that 
we  have  already  been  too  diffuse  on  this  subject,  we  should  have 
cited  in  this  place  the  interesting  facts  reported  in  the  excellent  work 
of  the  able  practitioners  whose  names  we  have  just  quoted. 

OF  INCLINATION,  AND  OF  OBLIQUITY  OF  THE  WOMB. 

Inasmuch  as  the  uterus  rarely  preserves  its  vertical  position,  when 
in  the  non-gravid  state,  it  is  easy  to  infer  that  its  lung  axis  may 
deviate  every  moment,  where  pregnancy  is  sufficiently  far  advanced 
to  allow  the  body  of  the  viscus  to  lift  itself  above  the  plane  of  the 
superior  strait.  Where  the  inclination  is  but  slight,  no  inconvenience 
is  experienced  from  it;  but,  if  the  fundus  of  the  womb  ceases  to  be 
mobile,  and  remains  constantly  leaning  to  either  of  the  sides,  such 
an  obliquity  constitutes  a real  malady  of  the  womb,  which  may  lead 
to  very  serious  consequences. 

The  works  of  the  father  of  medicine  contain  several  passages  to 
prove  that  his  attention  had  been  attracted  to  the  inclinations  of  the 
womb.  In  fact,  the  lateral  inclination,  or  latero-version,  seems  to  us 
to  be  clearly  pointed  out  in  the  passage  of  the  book : rifpt  ywaixfi^or 
CpVOiO'jj  (de  nut ura  mulier.)  where  he  says,  “ If  the  womb  bears  over 


INCLINATION,  OR  OBLIQUITY  OP  THE  WOMB.  173 

towards  the  iliac  region , the  belly  and  the  sides  become  painful ; 
a/id,  when  we  Touch , we  find  the  neck  of  the  womb  inclined  to- 
wards one  of  the  iliac  regions Aetius*  klso  speaks  of  the  inclina- 
tion of  the  womb  ; and,  in  explaining  the  doctrines  of  Aspasia  upon 
this  point,  he  adds  that  this  deviation  may  furnish  obstacles  in  the 
way  of  childbirth:  potest  et  difficult  as  pariendi  contingere,  ah 
cervicis  uteri  obliquiialem.  However,  the  obliquities  of  the  womb 
did  not  begin  to  fix  the  attention  of  practitioners  of  medicine  until 
Henry  Deventer,!  a celebrated  accoucheur  at  Groningen,  had  proved 
that  this  affection  is  among  the  principal  causes  of  difficult  labour,  and 
moreover  pointed  out  the  manoeuvre  required  by  cases  of  the  sort. 

Where  the  womb  is  found  to  be  inclined  forwards,  or  backwards, 
it  constitutes  nothing  more  or  less  than  the  first  stage  of  anteversion 
or  retroversion  ; when  it  is  to  one  side,  it  is  a latero-version , and  in 
such  a state,  the  neck  of  the  womb,  which  rises  higher  than  its 
natural  level,  inclines  its  orifice  towards  one  of  the  sides  of  the 
vagina,  and  the  patient  feels  in  various  degrees  the  symptoms  that 
proceed  from  anteversion. 

The  inclinations  occurring  during  pregnancy  have  received  from 
Deventer  the  appellation  of  obliquity  of  the  womb.  As  they  can 
only  take  place  to  one  side  or  to  the  front,  they  are  distinguished 
into  right  lateral,  left  lateral  and  anterior  obliquity;  a posterior 
obliquity,  notwithstanding  Levret’s  opinion  on  the  subject,  could  not 
take  place  in  a well-formed  woman,  since  it  is  prevented  by  the 
sacro-vertebral  projection. 

Obliquities  may  be  ascertained  to  exist  by  the  projection,  and 
resistance  of  the  fundus  uteri  against  the  abdominal  walls.  In  the 
anterior  obliquity,  the  upper  extremity  of  the  gestative  organ  is 
directed  forwards,  and  the  os  uteri  against  the  sacrum.  The  inclina- 
tion is  greater  in  proportion  to  the  number  of  preceding  pregnancies, 
and  it  is  found  to  increase  with  each  successive  one. 

In  some  women,  the  anterior  obliquity  is  found  to  be  so  great,  that 
the  belly  falls  down  over  the  external  organs  of  generation,  and 
sometimes  so  low  as  to  cover  the  thighs  even  down  to  the  knees. 

In  lateral  obliquity  the  fundus  forms  a prominence  at  one  side  of 
the  abdomen,  the  os  uteri  being  pointed  towards  the  opposite  side. 
The  anterior  inclination  is  the  one  most  frequently  met  with ; it  may 
depend  upon  the  relaxation  of  the  walls  of  the  abdomen,  upon  de- 
formity of  the  vertebral  column,  the  accumulation  of  a quantity  of 
fasces  in  the  colon,  or  any  other  cause  compelling  the  womb  to  in- 
cline itself  forwards. 

The  right  lateral  obliquity  is  also  pretty  frequent,  while  a left 
obliquity  is  quite  rare,  for  the  rectum  and  the  sigma  of  the  colon,  that 
are  often  distended  with  faeces,  prevent  the  womb  from  inclining  to 
that  side.  Besides  the  faulty  direction  of  the  pelvis,  lateral  obliquity 
has  been  assigned  to  a variety  of  causes,  such  as  shortness  of  one  of 
the  ligaments  of  the  womb,  a relaxation  of  one  side  and  constriction 

* Tetrab.  iv.,  Serm.  iv.  cap.  77. 

f Novum  Sumen  Obstetricantium,  1701,  et  ulterius  : examen.  partuum  difficultium, 

1725. 


174 


INCLINATION,  OR  OBLIQUITY  OF  THE  WOMB. 


of  the  opposite  one,  in  consequence  of  inflammation  or  spasm,  the 
habit  of  sleeping  always  on  one  side,  particularly  the  right  side ; and, 
finally,  the  existence  of  a considerable  tumour  in  the  abdomen  or  in 
one  of  the  ovaries.  Levret,  and  most  of  the  accoucheurs,  supposed 
obliquity  of  the  womb  to  depend  upon  an  attachment  of  the  placenta 
upon  one  side  of  the  uterus  that  was  drawn  downwards,  by  means 
of  the  weight  of  the  afterbirth.  Were  this  the  real  cause,  the  pla- 
centa would  be  more  frequently  found  upon  the  right  than  upon  the 
left  side,  and  in  front  more  frequently  than  on  the  posterior  surface, 
which  is  not  the  fact ; though  right  lateral  obliquity  takes  place  in 
ninety-nine  cases  in  a hundred,  while  posterior  obliquity  is  looked 
upon  as  nearly  an  impossible  state  in  a healthy  conformation  of  the 
pelvis  and  vertebral  column. 

[I  do  not  like  to  let  this  assertion  of  our  author  go  forth  without  protesting 
against  it,  as  being  unfounded  in  observation.  In  my  own  experience,  left 
lateral  obliquity  is  not  less  frequently  met  with  than  that  of  the  right  side  ; 
and  as  to  the  insertion  of  the  placenta,  no  man  knows  the  facts  as  to  its 
place  in  the  general.  No  man  can  have  such  knowledge,  since,  of  the  im- 
mense number  of  labours  that  are  superintended  by  medical  men,  in  a vast 
majority  of  them  the  placenta  is  detached  by  the  time  the  hips  of  the  child 
are  expelled,  or,  in  other  words,  by  the  same  contraction  that  effects  the 
expulsion  of  the  fcetus.  Medical  men  do  not  know,  therefore,  where  the 
afterbirth  is  attached,  except  in  those  cases  that  require  the  introduction  of 
the  hand  for  its  delivery.  According  to  Dr.  Churchill,  (see  Huston’s  edit., 
420,)  retention  of  the  placenta  has  occurred  once  in  66I3  times,  which  gives 
too  few  opportunities  to  admit  of  the  attainment  of  a correct  knowledge  of 
its  average  place  of  attachment.  I take  it  for  granted  that  practitioners  do 
not  go  after  the  placenta , except  under  a necessity  for  so  doing;  and  that 
when  the  placenta  presents  itself  at,  or  half  through  the  os  uteri,  imme- 
diately after  the  birth  of  the  child,  the  attendant  is  riot  competent  to  say  that 
it  was  in  this  or  that  special  place. — M.] 

While  the  inclinations  of  the  womb  that  take  place  in  its  non-gra- 
vid  state  are  but  little  worthy  of  our  regard,  those  that  occur  during 
gestation  are  of  real  importance.  According  to  Deventer,  they  may 
he  classed  with  the  most  fruitful  causes  of  difficult  parturition.  Even 
admitting  that  this  opinion  of  Deventer’s  is  a somewhat  exaggerated 
one,  it  is  easy  to  conceive  why  obliquity  may  not  unfrequently  occa- 
sion great  difficulty  and  delay  in  the  termination  of  a labour,  by 
reflecting  that  when  the  mouth  of  the  womb  is  impelled  against  one 
of  the  sides  of  the  pelvis,  the  expulsive  powers  cannot  act  in  the 
direction  of  the  vagina,  and,  of  course,  that  the  dilatation  will  not 
take  place,  except  with  difficulty  and  slowness.  Where  the  pelvis  is 
wide,  it  often  happens  that  the  descending  head  pushes  the  body  of 
the  womb  down  before  it,  so  that  it  comes  to  present  itself  at  the 
ostium  vaginae,  while  the  os  tincae  is  forcibly  driven  backwards : on 
the  other  hand,  where  the  pelvis  is  narrow,  the  womb  is  not  thrust 
downwards  by  the  head,  but  the  throes  that  tend  to  impel  the  head 


INVERSION  OF  THE  WOMB. 


175 


forwards  while  it  is  still  enclosed  in  the  cervix  uteri  may  give  rise 
to  contusions  of  the  part,  to  violent  distensions,  and  even  expose 
the  uterus  to  the  danger  of  becoming  inflamed,  or  of  being  lacerated, 
if  the  obliquity  be  not  speedily  rectified. 

Those  inclinations  that  take  place  in  the  non-gravid  womb  require 
no  special  treatment,  for  the  inconvenience  resulting  from  an  extreme 
obliquation  are  to  be  readily  remedied  by  means  of  a suspensory 
bandage  to  the  abdomen.  But  for  the  use  of  such  a precaution  the 
woman  would  suffer,  especially  towards  the  close  of  pregnancy,  from 
severe  pain  about  the  groins  and  loins,  and  a sort  of  numbness  upon 
the  side,  corresponding  with  the  obliquity. 

As  a measure  for  obviating  barrenness,  which  might  arise  from  a 
continued  obliquity  of  the  womb,  the  female  ought  to  lie  upon  the 
side  opposed  to  the  inclination  of  the  cervix,  durante  coilu  ; and  the 
same  precaution  should  be  taken  in  the  conduct  of  the  labour.  We 
should  endeavour  to  bring  the  fundus  of  the  womb  towards  the 
centre  of  the  abdominal  cavity,  by  supporting  and  pressing  the 
uterus,  with  a hand  laid  upon  the  abdomen.  Until  this  can  be  done, 
the  woman  ought  to  be  dissuaded  from  bearing  down.  If  such 
measures  were  to  prove  insufficient  to  replace  the  cervix  in  the  mid- 
dle of  the  excavation,  success  in  the  attempt  is  commonly  attainable 
by  the  use  of  two  of  the  fingers  hooked  within  the  orifice,  and  kept 
there  until  it  be  pretty  well  dilated,  and  the  bag  of  waters  formed. 
By  these  means,  which  are  equally  simple  and  easy  of  performance, 
the  patient  may  be  spared  many  pains,  while  the  favourable  position 
given  to  the  cervix  uteri  admits  of  its  easier  dilatation,  and  a con- 
siderable abridgment  of  the  duration  of  the  labour.  In  the  majority 
of  such  cases,  a venesection  will  be  found  to  be  indicated,  particularly 
if  the  mancguvre  here  recommended  should  not  have  been  put  in 
practice. 

OF  INVERSION  OF  THE  WOMB. 

Inversion  is  a case  in  which  the  womb  is  turned  inside  out,  either 
completely  or  partially,  like  a bag,  or  a glove-finger,  so  that  its  inter- 
nal surface  becomes  external,  and  vice  versa. 

Inversio-uteri,  which  may  take  place  either  while  the  womb  is  in 
a state  of  vacuity  or  during  parturition,  exhibits  several  degrees  or 
stages,  from  the  very  slightest  depression  of  the  fundus  to  the  com- 
plete turning  of  the  womb  inside  out,  so  that  the  body  of  the  viscus 
hangs  out  betwixt  the  thighs.  Daillez,  Levret,  and  most  of  the 
writers  on  the  subject,  have  admitted  but  two  varieties  of  this 
case,  which  are  the  incomplete  or  partial  inversion,  and  the  com- 
plete inversion.  The  former  is  when  the  fundus  has  fallen  down 
towards  the  orifice  and  projects  a little  into  the  vagina ; the  latter, 
or  the  complete  inversion,  is  when  the  womb  is  turned  entirely  inside 
out,  and  lies  in  the  canal  of  the  vagina,  or  escapes  quite  beyond  the 
orifice  of  the  vulva. 

Leroux,  of  Dijon,  establishes  three  degrees  of  inversion.  1.  A 
simple  depression  which  takes  place  when  the  top  of  the  womb  is 


176 


INVERSION  OF  THE  WOMB. 


somewhat  indented  like  the  bottom  of  a glass  bottle,  as  Mauriceau 
expresses  it.  2.  The  incomplete  inversion.  3.  The  complete  inver- 
sion, already  mentioned,  and  which  seems  to  be  intended  by  Hippo- 
crates, when  he  says  si  pudendo  exciderint  uteri , dependent  vetut 
scrotum. 

Finally,  Sauvages,  who,  like  ourselves,  classes  the  inversion  among 
the  lesions  of  situation,  and  arranges  it  as  a species  of  the  genus  Hys- 
teroptosis;  Professor  Delpech;*  Dr.  Ferrand,  in  his  excellent  Thesis ;t 
Madame  Boivin  and  M.  Duges4  admit  of  principal  degrees  of  this 
affection,  which  exhibit  distinctive  characters,  as  well  in  regard  to 
the  diagnosis  as  to  the  prognosis  and  treatment.  These  four  degrees 
may  remain  stationary,  others  may  be  progressive,  and  increase 
either  gradually  or  instantly  in  violence.  In  the  first  degree,  there 
is  simple  depression  of  the  fundus  uteri : in  the  second,  the  inverted 
fundus  disparts  the  os  uteri  a little — in  the  third,  the  inverted  organ 
is  lodged  in  the  vagina,  but  the  vaginal  orifice  of  the  womb  has  not 
participated  in  the  inversion,  and  lastly,  in  the  fourth  degree,  the 
rarest  of  all,  the  womb,  turned  inside  out,  forms  a considerable 
tumour,  which  may  be  augmented  inside  by  the  presence  within  it 
of  the  ligaments  of  the  womb,  and  by  a portion  of  the  intestines 
which  are  ingurgitated  in  the  new  cavity  formed  by  the  inverted 
organ.  The  mechanism  of  an  inversion  of  the  womb  is  very  easy  to 
be  understood.  The  fundus  of  the  organ,  which  is  carried  down- 
wards by  whatever  cause,  is  depressed  so  as  to  become  convex 
within  instead  of  concave,  as  in  its  natural  state.  This  depression 
increases  by  insensible  degrees,  and  passes  with  more  or  less  baste 
through  the  different  stages  of  inversion.  As  the  internal  face  sinks 
lower  and  lower,  it  drags  with  it  the  ligamenta  lata  and  ligamenta 
rotunda,  the  ovaries,  and  the  tubes,  which,  as  we  have  before  said, 
take  the  place  that  becomes  void  in  the  pelvis.  Inasmuch  as  the 
womb,  immediately  after  labour,  is  in  a condition  most  favourable 
to  the  occurrence  of  an  inversion,  that,  in  fact,  is  the  crisis  at  which 
such  an  event  is  most  likely  to  happen ; for  it  never  could  happen 
except  in  consequence  of  a distension  of  the  walls  of  the  womb, 
caused  either  by  the  presence  within  it  of  an  ovum,  a polypus,  or  a 
mole,  or  the  accumulation  of  a quantity  of  the  serum  of  the  blood 
within  its  walls. 

The  most  common  cause  of  inversion  consists  in  attempts  to 
deliver  the  placenta  immediately  after  the  birth  of  the  child  and 
before  the  womb  has  become  contracted.  2.  Too  powerful  efforts, 
of  traction  upon  the  cord  while  the  placenta  is  still  attached  to  the 
womb,  and  the  pressure  of  the  intestines  upon  the  fundus  at  the  same 
time.  3.  The  prolonged  efforts  at  bearing  down  that  some  women 
make  after  the  birth  of  the  child,  with  a view  more  speedily  to  expel 
the  placenta.  4.  The  spontaneous  violent  extraction  of  the  placenta, 
as  happens  when  women  are  delivered  in  a standing  posture,  which 
often  causes  the  sudden  and  simultaneous  escape  of  the  entire  pro- 

* Precis  des  Malad.  Reputees  Chir.,  iii.  p.  576. 

t Du  Renversement  de  la  Matrice.  diss  Maury.  Paris,  1828.  No.  278. 

* Traite  Prat,  des  Mai.  de  Uterus,  t.  i.  221,  1833. 


INVERSION  OF  THE  WOMB. 


177 


duct  of  the  conception,  particularly  if  the  umbilical  cord  happens  to 
be  too  short  or  twisted  round  the  child’s  neck  or  body.  Under  such 
circumstances,  should  the  placenta  be  adherent,  and  fail  to  become 
detached,  or  should  the  cord  not  break,  an  inversion  would  be  the 
almost  inevitable  consequence. 

Inversion  of  the  womb  is  not  always  due  to  the  imprudence  of 
the  attendant,  or  to  the  unfavourable  circumstances  by  which  the 
patient  is  surrounded  during  her  parturition : there  are  some  cases, 
certainly  rare  ones,  and  which  it  is  not  possible  to  foresee,  where  in- 
version occurs,  so  to  speak,  spontaneously,  and  without  any  external 
force  having  been  employed  to  pull  upon  the  internal  paries  of  the 
womb. 

The  women  most  liable  to  these  spontaneous  inversions,  as  they 
may  be  termed,  are  such  as  have  the  womb  distended  with  a great 
quantity  of  water  up  to  the  last  moments  of  the  labour ; such  as  lie 
in  almost  without  pain,  and  with  a single  bearing  down  effort ; cases 
where  both  the  child  and  the  afterbirth  are  very  large ; and  lastly, 
such  as  have  become  exhausted  by  long-protracted  sufferings.  All 
the  circumstances  which  may  become  occasional  causes  of  inertia 
uteri,  and  which  make  the  patient  liable  to  flooding  after  delivery, 
are  also  to  be  regarded  as  so  many  predisposing  causes  of  the  affec- 
tion under  consideration.  To  the  predisposing  causes  we  may  add 
the  antecedent  occurrence  of  an  inversion  in  labour,  though  promptly 
relieved ; a chronic  state  of  prolapsion  of  the  vagina  and  womb, 
and  a certain  laxity  of  these  organs  attributed  to  persons  of  a lym- 
phatic temperament.  It  happens,  in  certain  instances  of  this  sort, 
that  the  softness  and  flaccidity  of  the  uterus  are  so  great,  that  even 
after  a careful  delivery,  the  mere  pressure  of  the  superincumbent 
bowels  on  the  fundus  uteri  causes  it  to  be  inverted  without  any  trac- 
tion having  been  made  upon  the  cord.  It  is  easy  to  conceive  the 
possibility  of  an  inversion,  caused  by  the  weight  of  the  bowels  press- 
ing upon  the  summit  of  the  organ,  if  we  reflect  that  the  impulse  may 
be  very  sudden  and  violent,  as  from  the  contraction  of  the  diaphragm 
and  abdominal  muscles  in  coughing,  sneezing,  vomiting  or  imprudent 
movements  of  the  patient. 

Notwithstanding  inversion  of  the  womb  would  appear,  in  a man- 
ner, to  be  impossible,  except  immediately  subsequent  to  the  escape 
of  the  foetus  from  its  cavity,  which  is  the  period  when  the  viscus  is 
most  expanded  and  most  flexible;  both  Ane  and  Baudelocque*  bear 
witness  to  its  having  occurred  upon  the  third  day,  and  Leblanct  on 
the  tenth  day  after  delivery.  Professor  Desormeauxf  reports  that  he 
was  consulted  for  the  case  of  a woman  in  whom  there  was  an  incom- 
plete inversion,  which  was  not  detected  until  twenty-one  days  after 
the  childbirth. 

[I  have  seen  a case  in  this  city  in  which  the  occurrence  was  not  verified 

* Diss.  inaug.  du  Dr.Daillez,  1803. 
f Sabatier,  Mem.  sur  les  Deplacements  de  TUterus. 
i Diet,  de  Med.,  21  vol.  t.  xviii.,  p.  227. 

12 


178 


INVERSION  OF  THE  WOMB. 


until  thirty  days  after  labour,  and  another  in  which  eighteen  months  elapsed 
before  the  fact  was  ascertained. — M.] 

We  opine  that  complete  inversion,  discovered  so  late,  must  have 
existed,  in  an  incomplete  stage,  beforehand;  and  that  commonly  they 
must  have  commenced  immediately  after  delivery.  Were  this  not 
the  case,  the  womb,  doubtless,  must  have  continued  distended  with 
coagula,  and  thus  have  retained  the  same  volume  and  flaccidness  as 
belong  to  it  after  the  sudden  expulsion  of  the  ovum. 

Inasmuch  as  an  antecedent  dilatation  and  softness  of  the  uterine 
parietes  are  the  prime  conditions  for  a possible  inversion,  it  is  appa- 
rent that  a lying-in  is  not  the  sole  predisponent  cause  of  the  accident ; 
in  fact,  an  inversion  may  take  place,  not  only  long  subsequent  to 
childbirth,  but  even  in  women  who  have  never  borne  children.  For 
example,  inversion  has  been  observed  to  follow  immediately  upon 
the  expulsion  of  a large  polypus,  or  upon  tractile  efforts  made  upon 
such  a tumour,  where  its  pedicle  has  been  implanted  in  the  fundus, 
which  has  been  drawn  down  by  the  footstalk,  into  the  vagina.  Goul- 
lard,*  Culleriert  and  Denmanf  report  cases  occurring  in  this  way. 

This  affection  may  also  arise  from  a distension  of  the  womb,  caused 
by  a dropsy,  or  an  accumulation  of  blood  in  the  organ, § whose 
walls  being  relaxed,  thinned  and  weakened,  yield  readily  to  the  im- 
pulsion of  the  bowels,  and  the  contractions  of  the  abdominal  mus- 
cles, as  soon  as  the  foreign  substances  have  suddenly  escaped  from 
its  cavity.  All  these  circumstances  may,  to  a certain  extent,  be  com- 
pared with  those  existing  at  the  period*  of  delivery  in  childbirth  ; for 
the  walls  of  the  womb  being  then  nearly  in  the  same  condition  as 
in  parturition,  yield  to  the  slightest  impulses,  or  the  least  effort. 
However,  Puzos,  who,  as  well  as  Vigaroux,  looked  upon  excessive 
obesity  as  an  exciting  cause  of  inversion,  read  at  the  Academy  a 
memoir,  a mere  extract  of  which  only  remains  at  the  present  day,|| 
wherein  he  relates  several  cases  of  inversion  observed  by  himself  in 
females  who  had  never  borne  children,  or  who  had  never  experi- 
enced any  indisposition  during  fifteen  or  twenty  years  subsequent 
to  their  last  confinement.  Notwithstanding  the  authority  of  these 
two  great  practitioners,  we  agree  with  Gardien  and  Desormeaux,  that 
it  is  not  to  be  supposed  that,  in  the  cases  mentioned  by  Puzos,  the 
cause  of  the  accident  could  have  been  merely  the  obesity  and  the 
weight  of  the  bowels  resting  on  the  womb  so  long  non-gravid. 
Boyerf  cites  a similar  example  from  a female  who  had  had  no  child 
for  fifteen  years,  and  whose  womb  certainly  contained  no  foreign 
body.  As  the  inversion  in  this  case  was  not  complete,  and  it  being 
probable  that  the  same  was  the  fact  in  Puzos’  cases,  we  must  con- 
clude that  the  affection  was  of  a very  ancient  date,  and  remained 
undetected  for  a number  of  years,  because  the  fundus  of  the  womb 

* Mem.  de  l’Acad.  des  Sci.,  1732,  and  Mem.  de  l’Acad.  de  Chir.,  t.  iii.,  p.  377. 
j-  Nauche,  Malad.  des  Femmes.,  t.  i.,  p.  133. 
t Plates  of  a Polypus  with  an  Inversion  of  the  Uterus,  1801. 

§ Leblanc  d’Orleans;  Mem.de  l’Acad.  de  Chirurg.,  iii.,  379. 

||  Inserted  in  le  Mercure  de  France,  ann.  1744. 

1 Traite  des  Mai.  Chirurg. 


INVERSION  OP  THE  WOMB. 


179 


being  but  slightly  depressed,  particularly  at  the  period  of  the  last 
confinement,  the  patient’s  health  was  undisturbed  up  to  the  time 
when  the  inversion,  by  a gradual  progress,  had  attained  to  a greater 
degree  of  completeness.  What  tends,  moreover,  to  militate  in  favour 
of  this  hypothesis  is,  that  the  records  of  the  science  contain  nume- 
rous cases  of  women  who  have  continued  in  tolerable  health  during 
many  years,  under  inversion  of  the  womb,  even  when  absolutely 
complete.  Thus,  Delamotte*  says  he  knew  a woman  who  had  had 
a complete  inversion  for  thirty  years ; Levret,t  in  a woman  sixty 
years  of  age,  found  an  enormous  tumour  constituted  of  the  inverted 
womb  and  vagina,  the  ovaries,  the  tubes,  with  a portion  of  the  rec- 
tum, and  of  the  bladder  and  small  intestines.  Dr.  Daillezf  states  that 
Baudelocque  met  with  an  inverted  womb  in  the  case  of  a young  girl 
fifteen  years  old,  and  he  adds,  that  it  could  not  have  been  in  conse- 
quence of  a clandestine  delivery,  because  the  hymen  was  perfect. 
This  peculiarity  seemed  to  Baudelocque  so  extraordinary  that  he 
looked  upon  it  as  the  result  of  a congenital  deformity,  for  he  could 
not  be  persuaded,  and  very  properly  so,  that  the  organ  could  be  the 
subject  of  an  inversion  without  any  antecedent  dilatation.  Baron 
Dubois  supposed  that  the  celebrated  author  might  have  been  led  into 
error  by  a polypus  uteri.  As  we  do  not  think  it  possible  for  Baude- 
locque to  make  such  a mistake  in  diagnosis,  though  such  mistakes 
are  not  wanting,  we  conceive  it  possible  that  the  inversion  he  met 
with,  in  the  young  girl,  might  have  taken  place,  in  consequence  of 
the  distension  of  the  parietes  of  the  womb,  produced  by  a retention 
of  the  menses,  the  accumulation  of  serum,  or  the  extrication  of  gases 
in  the  organ,  and  subsequently  expelled  suddenly.  In  fine,  we  may 
add  to  the  above,  the  case  recently  noticed  by  M.  Duges,§  who  in- 
forms us  of  a lady  whom  he  saw  in  consultation  with  the  Messrs. 
Dubois,  sen.  and  jun.,  who  laboured  for  five  years  under  an  inver- 
sion of  the  womb,  without  suffering  any  inconvenience  beyond  a 
sense  of  dragging  weight  about  the  groins  and  loins,  and  frequent 
desire  to  pass  the  urine,  but  which  went  off  as  soon  as  she  laid  her- 
self down. 

Previous  to  closing  our  remarks  upon  the  causes  of  inversion,  let 
us  add  that  Dessault,  and  Herbiniaux  proposed  that  inversion  should 
be  temporarily  induced  in  the  case  of  polypus  of  large  size,  by  draw- 
ing it  downwards,  with  a view  of  enabling  the  operator  to  adjust  a 
ligature  more  easily  upon  the  neck  of  the  tumour.  According  to 
Desormeaux,  this  plan  was  executed  successfully,  not  only  by  the 
two  distinguished  practitioners,  but  by  several  other  operators. 

The  symptoms  of  the  affection  in  question  are  different,  according 
to  the  degree  in  which  it  happens  to  exist,  the  circumstances  which 
accompanied  the  accident,  and  the  fact  of  it  having  occurred  sud- 
denly or  by  degrees. 

A mere  depression  of  the  fundus  of  the  womb  generally  lasts  but  a 

* Observ.  412. 

f Obs.  sur  les  Polypes  de  la  Matrice,  p.  140. 

* Precis  des  Lemons  de  Baudelocque,  sur  le  Kenversement  de  la  Matrice,  1803. 

§ Traite  des  Mai.  de  l’Uterus,  t.  i.  p.  245. 


130 


INVERSION  OF  THE  WOMB. 


short  time ; it  is  either  soon  followed  by  the  reposition  of  the  organ, 
or  by  its  rapid  transition  to  a further  degree  of  inversion.  This 
slight  uterine  inversion,  which  constitutes  the  first  stage,  may  be  dis- 
covered by  the  painful  sense  of  dragging  that  the  woman  complains 
of,  when  tractions  are  made  at  the  cord  of  a still  adhering  placenta, 
or  by  the  cup,  like  the  bottom  of  a bottle,  that  may  be  felt  through  the 
abdominal  teguments  by  placing  the  hand  upon  the  hypogaster ; in 
such  case  it  is  of  the  highest  moment,  not  only  to  desist  from  pulling  at 
the  cord,  but,  moreover,  to  command  the  woman  to  abstain  from  every 
attempt  to  bear  down,  which  would,  without  promoting  the  delivery 
of  the  afterbirth,  inevitably  increase  the  inversion.  We  ought  here 
to  try  to  detach  the  placenta,  by  introducing  a hand  into  the  womb, 
taking  care  to  act  from  the  circumference  to  the  centre  of  the  after- 
birth, and  to  restore  to  the  uterus  its  proper  form,  by  pushing  up  the 
fundus,  while  gentle  tractions  at  the  cord,  with  the  other  hand,  ena- 
ble us  to  conclude  the  delivery. 

The  signs  and  symptoms  of  inversion  in  the  second,  are  analogous 
to  those  of  the  first  stage,  and  differ  from  them  only  as  being  more 
evident,  and  attended  with  severer  pain.  Where  the  inversion  has 
continued  for  some  time  after  delivery,  the  diagnosis  becomes  rather 
obscure,  because  the  mouth  of  the  womb  surrounds  the  summit  of  the 
tumour,  just  as  it  does  in  the  case  of  polypus;  though,  in  this  condition, 
the  summit  of  the  tumour  formed  by  the  inverted  fundus  descends 
so  low  as  to  press  open  the  os  uteri,  the  finger  can  only  touch  a con- 
vex surface  whose  nature  is  equivocal,  and  around  which  it  is  impos- 
sible to  penetrate  in  order  to  feel  and  explore  it.  Nothing,  therefore, 
except  the  surpubal  palpation,  and  the  Touch  by  the  rectum,  can  re- 
move the  obscurity  of  the  case.  In  the  third  stage,  the  Touch  by  the 
rectum  and  hypogastrium  furnishes  more  positive  data  than  can  be 
got  in  the  second  stage  of  inversion.  We  can  here  readily  ascertain 
that  the  womb  has  abandoned  its  natural  position,  if,  as  should  always 
be  done,  we  take  care  beforehand  to  cause  the  bladder  and  rectum 
to  be  evacuated,  and  to  place  the  abdominal  muscles  in  the  greatest 
possible  relaxation.  The  womb  is  found  to  be  lodged  within  the 
vagina,  as  a distinct  tumour,  and,  as  it  were,  strangulated  by  the  os 
uteri,  which  alone,  of  all  parts  of  the  organ,  has  escaped  the  act  of  in- 
version. Continual  haemorrhages,  exhausting  to  the  patient,  have  often 
led  to  the  suspicion  that  the  tumour  composed  of  the  inverted  uterus 
was  nothing  more  than  a polypus  adhering  to  the  fundus  uteri.  Such 
a mistake  as  this  is  easily  avoided,  by  observing  that  the  neck  or  pe- 
dicle of  a polypus  is  narrower  and  more  elongated  than  that  observed 
in  inversion,  in  which  we  have  a tumour  larger  below  than  above, 
more  or  less  reducible,  and  possessing  a lively  sensibility ; the  poly- 
pus, on  the  contrary,  has  very  little  sensibility  to  the  touch,  and  is 
irreducible.  It  is  true  that,  in  either  case,  the  os  uteri  forms  a sort  of 
ring  round  the  root  of  the  tumour,  but  this  ring  is  less  salient  in  the 
case  of  inversion,  and  does  not  admit  of  the  passage  of  the  finger  or 
of  a sound  more  than  a few  lines  upwards  to  its  cul-de-sac ; while, 
should  the  ring  embrace  only  the  neck  of  a polypus,  the  sound  could 
be  made  to  pass  far  upwards  without  difficulty.  Further,  when  the 


INVERSION  OP  THE  WOMB. 


181 


tumour  is  a polypus,  the  fundus  of  the  womb  may  be  felt  above  the 
top  of  the  pubis,  in  many  cases,  especially  in  emaciated  or  thin 
persons— unless,  indeed,  by  the  weight  of  the  polypus,  the  womb 
should  be  dragged  down  into  the  bottom  of  the  pelvis.  In  fine,  to 
avoid  confounding  together  an  inversion  and  a prolapsion  of  the 
womb,  in  which  there  are  symptoms  common  to  both  of  them,  such 
as  the  dragging  weight  at  the  groins  and  the  back,  &c.,  it  should 
be  remembered  that  in  prolapsus  there  is  no  ring  formed  by  the  os 
uteri  like  that  in  inversion  ; and  that  whereas,  in  the  latter  case,  the 
tumour  is  pear-shaped,  as  it  is  in  the  former,  the  contracted  part  is 
above  and  the  largest  part  below,  while  the  contrary  obtains  in  the 
case  of  hysteroptosis. 

It  is  far  easier  to  recognize  inversion  of  the  womb  when  in  the 
fourth  stage.  The  tumour,  which,  for  the  most  part,  projects  beyond 
the  vulva,  is  generally  larger  than  in  the  other  stages,  although  still 
partially  reducible,  and  is  covered  with  dark-looking  bloody  excre- 
tion, especially  when  the  inversion  is  a recent  accident.  In  this  con- 
dition it  is  found  to  increase  and  diminish  in  size  alternately,  accord- 
ingly as  it  happens  to  contain  portions  of  the  intestinal  convolutions 
or  not,  since  they  are  occasionally  present  within  the  tumour,  and  then 
withdrawn  from  it.  When  it  remains  partly  within  the  vagina,  the 
finger  introduced  into  the  vagina,  betwixt  it  and  the  tumour,  always 
encounters  a cul-de-sac,  situated  at  an  elevation  different  in  different 
subjects,  and  preceded  by  a sort  of  ring  marked  in  relief  at  the  most 
constricted  part  of  the  tumour ; and,  lastly,  by  touching  the  hypo- 
gastrium,  we  ascertain  that  the  womb  has  completely  abandoned  its 
natural  situation. 

Generally  speaking,  where  inversion  is  about  commencing,  or  in 
its  first  or  second  stage,  it  is  signified  by  a haemorrhage,  if  it  follows 
a labour,  and  by  an  increased  menstruation  and  leucorrhoeal  dis- 
charge where  it  takes  place  under  other  circumstances.  To  these 
symptoms  are  added  violent  pain  and  draggings  at  the  groins  and 
back,  with  a feeling  of  weight  within  the  pelvis.  The  same  symp- 
toms are  more  strongly  marked  in  the  two  last  stages,  to  such  a de- 
gree, indeed,  that  the  flooding,  which  is,  particularly  in  the  third  stage, 
the  principal  symptom,  becomes  so  violent  as  to  prove  rapidly  fatal. 
There  are  lacerating  pains  felt,  accompanied  with  syncope,  that  are 
generally  mitigated  by  pressing  the  womb  upwards  into  the  vagina, 
though  they  are  sometimes  observed  to  increase  during  attempts  at 
reduction.  Lastly,  inflammation  and  gangrene,  which  not  rarely 
attack  the  inverted  portion  of  the  womb,  are  especially  to  be  feared 
where  the  organ  is  pendulous  outside  of  the  genital  fissure. 

Inversion  of  the  womb  is  a dangerous  accident,  that  may  prove 
speedily  mortal,  provided  there  be  the  least  delay  in  attending  to  the 
reposition  of  the  organ,  and  the  sooner  after  parturition  it  occurs, 
the  more  dangerous  it  is  to  be  esteemed.  Notwithstanding  some 
women  have  been  known  to  live  very  long  although  affected  even 
with  a complete  inversion,  unreduced,  it  generally  happens  that  the 
few  who  do  survive,  draw  out  a miserable  existence,  and  perish  at 
last,  being  exhausted  by  profuse  leucorrhoea  and  repeated  attacks  of 


182 


INVERSION  OF  THE  WOMB. 


flooding.  The  reposition  of  the  inverted  organ,  which  offers  the  sole 
chance  of  cure,  and  which  is  generally  quite  easy  of  accomplishment, 
when  undertaken  immediately  after  the  accident,  becomes  more  and 
more  difficult  the  longer  it  is  deferred,  and  often  becomes  wholly  im- 
possible. However,  there  are  several  examples,  going  to  show  that 
the  reposition  has  been  successfully  performed  as  late  as  the  fifth  day, 
the  eighth  day,  and  even  much  later.  Dr.  Daillez  reports,  in  his  dis- 
sertation, that  the  surgeon  Labarre  de  Benzeville  had  effected  the 
reduction  as  late  as  the  eighth  month  ; and  Baudelocque  after  eight 
years.  Gardien  refers  to  the  last-named  author,  for  an  instance  in 
the  wife  of  a vine-dresser  at  Ruel,  where  the  womb  was  reduced 
eight  days  after  the  labour,  by  M.  Ane.  Moreover,  the  organ,  after 
having  been  long  inverted,  has  been  seen  to  reduce  itself  spontane- 
ously, in  consequence  of  a violent  accidental  shock ; and,  from  a let- 
ter by  Laroux,  addressed  to  Louis,  which  is  mentioned  in  Daillez ’ 
Thesis , the  spontaneous  reposition  of  the  womb  has  been  known  to 
take  place  two  months  after  the  occurrence  of  the  accident. 

[I  take  occasion  here  to  offer  some  remarks  upon  spontaneous  reposition 
of  the  womb  after  inversion,  since  I have  been  very  deeply  interested  in  the 
subject,  from  having  met  with  two  cases  of  the  accident,  in  which  the  womb 
not  only  recovered  spontaneously,  but  in  which  the  woman  became  after- 
wards pregnant.  This  statement  appears  so  extraordinary,  when  unsupported 
by  the  cases  cited  by  our  author  in  the  foregoing  passages,  that  I might  justly 
deem  it  an  imprudence  to  make  a statement  of  them  were  it  supported  by 
my  sole  authority. 

I shall  begin  by  remarking  that  a very  complete  inversion  of  the  womb 
is  not,  if  it  be  early  reposited,  to  be  considered  as  obviating  the  liability 
of  the  patient  to  a subsequent  conception.  This  I can  clearly  aver  upon 
the  facts  in  the  case,  published  by  me  in  the  Phil.  Pract.  of  Mid.,  2d  edit., 
p.  356,  where  the  case,  as  seen  by  the  late  Dr.  James,  Professor  of  Mid- 
wifery in  the  University  of  Pennsylvania,  by  Dr.  George  Fox,  of  this  city, 
and  by  myself,  is  given  at  large.  In  that  case  the  inversion  was  produced 
by  violent  and  most  painful  tractions  at  the  cord  by  an  ignorant  midwife, 
who  supposed,  after  she  had  drawn  the  womb  entirely  forth  of  the  patient’s 
body,  that  the  huge  mass  consisted  of  some  unnatural  state  of  the  placenta, 
which,  in  fact,  was  adherent  to  it.  The  midwife,  even  after  the  womb  was 
withdrawn  and  hanging  between  the  thighs  of  the  woman,  made  violent 
efforts  to  pull  it  away  from  her,  and  only  desisted  in  consequence  of  her 
screams,  and  the  apparent  approach  of  death. 

I reposited  this  womb,  not  by  compressing  the  organ  between  my  hands, 
as  it  is  usually  directed  to  be  done,  but  by  waiting  until  the  contraction  or 
after-pain  had  ceased,  and  then  indenting  the  fundus  with  a finger,  like  the 
bottom  of  a bottle,  and  suddenly  pushing  the  cone  upwards  to  the  os  uteri, 
and  so  into  the  belly  again.  This  patient  was  as  nearly  dead  from  haemor- 
rhage as  any  woman  1 have  seen  recover  from  flooding.  Upon  the  re-esta- 
blishment of  her  health  she  bore  children,  and  in  two  instances  was  delivered 


INVERSION  OF  THE  WOMB. 


183 


by  my  friend  and  colleague;  Professor  F.  Bache,  of  Jefferson  Medical  Col- 
lege. 

I mention  these  circumstances  in  order  to  show  that  the  extremest  degree 
of  inversion — none  could  be  more  complete — is  not  necessarily  the  cause 
of  lesions  to  the  ovaries,  tubes  and  other  organs  connected  with  reproduc- 
tion, so  great  as  to  deprive  them  ever  afterwards  of  the  reproductive  power. 

I saw,  a few  years  since,  a female  in  this  city,  who  had  been  the  subject  of 
an  inversion  of  the  womb  for  about  two  years.  This  took  place  at  the  time  of 
her  confinement,  when  she  had  a very  profuse  haemorrhage,  so  as  to  be  sup- 
posed to  be  in  danger  of  a fatal  result.  Her  health  gradually  improved,  but 
she  remained  subject  to  frequent  attacks  of  haemorrhage,  by  which  her 
strength  became  again  much  reduced.  At  length,  a physician,  who  was  called 
in,  detected  the  existence  of  inversion  of  the  womb,  and  invited  me  to  exa- 
mine the  case  and  verify  the  diagnosis.  I found  the  womb  projecting  into 
the  vagina,  and  I believe  it  to  have  been,  at  the  time,  completely  inverted.  It 
was  not  much  larger  than  the  non*gravid  womb,  bled  readily  from  pressure 
at  the  time,  and  was  not  very  sensible  to  touch,  as  indeed  the  healthy  uterus 
is  not. 

In  this  case  I made  the  most  careful  attempt  to  discriminate  between 
polypus  and  inversio-uteri,  and  I remained  under  the  absolute  conviction,  as 
did  the  physician,  Dr.  Moehring,  a highly  capable  practitioner,  that  the  case 
was  one  not  of  polypus,  but  of  inversion.  I gave  such  a prognosis  as  I 
deemed  reasonable,  but  added  to  it  the  opinion  that  she  would  never  again 
be  subject  to  conception.  This  female  was  subsequently  examined  with 
care  by  Professor  Hodge,  of  the  University  of  Pennsylvania,  with  the  same 
diagnostic  result;  and  later  by  Dr.  Warrington,  of  this  city,  well  known  as 
a teacher  and  practitioner  of  obstetrics.  These  gentlemen  all  agree  that  the 
case  was  one  of  inversion,  and  the  attempts  made  by  myself  and  by  them, 
to  reposit  the  organ  were  without  the  least  success.  Nevertheless,  after  some 
four  years  posterior  to  the  period  of  my  visit  to  her,  she  became  pregnant,  and 
miscarried  of  an  embryo  of  more  than  three  months,  under  the  care  of  Dr. 
Warrington,  who  received  the  embryo,  and  who  feels  as  much  surprised  as 
I do  at  the  circumstance.  I may  take  the  occasion  to  say  that  Dr.  Hodge 
and  Dr.  Warrington  have  assured  me  of  their  convictions  of  the  correctness 
of  their  diagnosis  in  the  case,  and  I may  add,  that  I have  not  the  least  doubt 
of  its  correctness,  for  I do  not  think  I could  make  so  gross  a mistake  where 
my  careful  attention  had  been  given  to  the  formation  of  a correct  opinion. 
Far  less  can  I suppose  that  the  other  gentlemen  could  be  equally  mistaken. 

May  5th,  1841. — I saw,  in  company  with  Dr.  Levis,  of  the  city,  Mrs.  S., 
aged  twenty-seven  years.  She  has  two  children,  the  youngest  born  five 
weeks  ago.  Dr.  L.  informed  me  that  the  child  was  expelled  before  he 
reached  her  dwelling.  Upon  arriving  there,  he  found  her  lying  upon  her 
back,  near  the  edge  of  the  bed,  the  feet  resting  upon  chairs,  as  if  she  had 
hardly  found  time  to  get  upon  the  bed  before  the  escape  of  the  foetus,  which 
an  attendant  was  then  holding  up  in  her  hands,  in  order  to  keep  it  out  of 


184 


INVERSION  OF  THE  WOMB. 


the  great  pool  of  blood  collected  about  the  hips  of  the  patient.  The  child’s 
head,  indeed,  was  quite  born  before  the  lady  could  rise  from  the  pot-de- 
chambre,  on  which  she  had  placed  herself.  Dr.  L.  removed  the  placenta 
from  the  vagina,  having  found  the  womb  contracted. 

After  the  delivery,  she  flooded  a good  deal,  but,  in  a fortnight,  was  much 
recovered.  Subsequently  to  this  period,  she  was  seized  with  flooding  of 
a severe  character,  since  which  she  has  not  been  free  from  bloody  dis- 
charges, which  are  occasionally  quite  copious.  Two  days  ago,  the  doctor 
examined  his  patient,  and  found  a tumour  projecting  from  the  os  uteri, 
which  he  suspected  to  depend  upon  inversion  of  the  organ.  She  is  now 
very  feeble,  is  bleeding,  and  has  frequent  fits  of  hysterical  delirium. 

Upon  Touching  per  vaginam,  and  upon  inquiry  made  by  means  of  the 
speculum,  and  even  by  disparting  the  labia  with  two  fingers  of  each  hand, 
it  was  easy  to  discover  a tumour  which  bore  so  great  a resemblance  to  an 
uterine  polypus  that  it  was  difficult,  viewing  its  size,  form,  colour  and  resist- 
ance, to  believe  that  it  was  not  a polypus  which  had  existed  throughout  the 
gestation ; an  idea  which  yet  could  not  be  very  reasonably  indulged,  seeing 
she  had  gone  through  a healthful  pregnancy  to  full  term ; though  I admit  its 
possibility  in  certain  cases.  As  the  parts,  as  well  as  her  whole  frame,  were 
very  much  relaxed,  I introduced  half  of  my  right  hand  into  the  vagina,  be- 
hind the  tumour,  so  as  to  enable  me  to  carry  two  fingers  quite  far  up  into 
the  cul-de-sac,  behind  the  cervix  uteri,  which  was  not  inverted.  Having 
thus  possession  of  the  canal,  I carried  the  two  fingers  forcibly  upwards  and 
forwards,  so  near  to  the  margin  of  the  superior  strait,  just  behind  the  sym- 
physis pubis,  that  the  fingers  of  my  left  hand,  pressed  forcibly  upon  the 
lower  part  of  the  hypogastrium,  were  but  a very  small  distance  from  those 
of  the  right  hand  within  the  vagina.  They  approached  so  near  to  each  other 
that  I remained  perfectly  convinced  that  no  womb  was  interposed  betwixt 
them,  and  that  the  tumour  within  the  vagina  consisted  of  the  inverted  womb, 
and  nothing  else.  She  remained  for  some  time  feeble,  and  subject  to  haemor- 
rhage, which  gradually  disappeared.  She  made  a journey  to  one  of  the 
Western  States,  and  returned  to  the  city;  since  which  she  became  pregnant 
and  gave  birth  to  a child. 

Now,  in  these  two  cases,  I am  very  confident  of  my  diagnosis;  and,  since 
both  these  women  have  been  the  subjects  of  conception  and  pregnancy, 
without  artificial  reposition  of  the  organ,  I rest  convinced  that  the  inverted 
womb,  where  the  accident  does  not  prove  suddenly  mortal  by  hemorrhage, 
nor  slowly  fatal  from  exhaustion  by  inflammation  and  gangrene,  or  discharges, 
may  reposit  itself  in  some  rare  instances.  I have  made  a statement  of  these 
cases  to  Dr.  J.  Greene  Crosse,  of  Norwich,  England,  to  whom  the  profession 
is  about  to  be  indebted  for  a work  upon  inversion  of  the  womb,  which  I 
impatiently  expect.  I draw  from  my  experience  in  these  cases,  and  from 
what  is  stated  by  M.  Colombat,  much  consolation  for  those  women  who  are 
so  unhappy  as  to  be  affected  with  inversion  of  the  womb,  irreducible  by 
manual  aid. — M.] 


INVERSION  OF  THE  WOMB. 


185 


The  treatment  of  inversion,  like  the  other  displacements  of  the 
organ,  presents  two  chief  indications,  which  are,  to  restore  the  womb 
to  its  natural  situation,  and  to  provide  against  a recurrence  of  the 
accident. 

All  practitioners  are  agreed  that  the  most  favourable  moment  for 
operating  a reduction  is  that  which  immediately  succeeds  the  occur- 
rence. It  is  always  easy  to  reduce  it,  when  in  the  tirst  stage,  and 
where  it  has  taken  place  previous  to  the  deliverance  of  the  placenta ; 
all  that  is  necessary  being  to  carry  two  fingers  into  the  vagina,  so  as  to 
push  the  placenta  upwards  sufficiently  to  make  the  womb  recover  its 
natural  shape  and  situation.  On  the  other  hand,  where  inversion,  in- 
complete, takes  place  after  delivery,  far  from  trying  to  carry  the  hand 
up  to  the  depression,  within  the  uterine  cavity,  we  should  confine 
ourselves  to  an  attempt  to  excite  the  uterine  contractions  by  irritating 
the  os  tincae,  and  by  applying  cold  cloths  to  the  upper  part  of  the 
thighs  and  the  external  genitalia,  or  by  making  use  of  stimulating 
frictions  at  the  hypogastrium,  and  particularly  over  the  ligaments  of 
the  womb.  Should  the  placenta  be  still  found  adherent  to  the  fundus 
uteri,  and  the  flooding  not  prove  alarming,  we  ought,  before  detach- 
ing it,  to  wait  until  the  uterine  contractions  become  established  again. 
However,  in  case  of  a complete,  or  nearly  complete  inversion,  with 
abundant  discharge  of  blood,  especially,  I should  not  hesitate,  not- 
withstanding the  opinion  of  Dr.  Ferrand  and  most  other  persons  to 
the  contrary,  to  extract  the  placenta  as  soon  as  practicable,  by  de- 
taching it  with  the  fingers,  acting  from  the  edge  to  the  centre,  so  as 
to  avoid  any  traction  on  the  centre  of  the  fundus : this  I should  do 
previously  to  any  attempt  at  reduction,  which  is  far  easier  when  the 
womb  is  empty.  In  this  case,  it  is  important  to  act  without  delay, 
because  the  placenta,  which  is  generally  attached  to  the  womb  only 
by  some  distinct  portions  of  the  surface,  the  rest  being  detached 
already,  serves,  by  its  presence,  rather  to  keep  up  than  to  lessen  the 
flooding,  as  is  generally  thought.  Where  the  inversion  takes  place 
after  the  delivery  of  the  placenta,  or  the  escape  of  any  foreign  body, 
we  should  most  expeditiously  profit  by  the  occasion  of  the  greatest 
degree  of  relaxation  to  anoint  the  right  hand  and  carry  it  into  the 
vagina,  while  the  left  is  placed  upon  the  hypogastrium,  with  a view 
to  support  the  uterus,  while  we  push  up  the  inverted  portion  with 
the  hand  that  is  inside,  and  which  ought  to  be  kept  thus  after  the 
reposition,  until  it  be  well  contracted ; an  event  that  may  be  pro- 
moted by  frictions  above  the  pubis,  with  the  left  hand.  The  patient 
should  be  advised  to  avoid  bearing  down,  to  breathe  very  gently,  to 
moderate  her  cries  or  exclamations,  and  to  observe  a horizontal  pos- 
ture, and  be  as  still  and  calm  as  possible.  After  having  continued 
the  frictions  for  some  time,  the  womb  should  be  kept  compressed  by 
means  of  a folded  napkin,  secured  by  a binder  round  the  body. 

Pretty  much  the  same  method  should  be  followed,  in  the  case  of 
an  inversion  taking  place  immediately  after  the  delivery  of  the  foetus 
and  afterbirth.  The  reduction  should  be  performed  by  placing  the 
patient  upon  her  bed,  with  the  hips  elevated  higher  than  her  chest, 
the  legs  drawn  upwards  and  flexed;  then,  with  the  right  hand  seizing 


186 


INVERSION  OF  THE  WOMB. 


the  parts  nearest  to  the  pedicle,  that  is,  those  that  are  highest,  and 
which,  of  course,  were  the  last  inverted,  they  should  be  pressed 
upwards,  and  made  to  re-enter  first ; then,  in  succession,  we  should 
push  up  the  fundus,  along  the  lateral  parts,  which  should  be  made, 
little  by  little,  to  pass  through  the  os  uteri,  imitating  the  manoeuvre 
made  use  of  in  reducing  a strangulated  hernia.  There  is  also  another 
but  less  reasonable  method  which  has  been  recommended,  and  which 
consists  in  depressing,  with  the  hand,  the  fundus  into  the  globe 
formed  by  the  inverted  organ,  and  proceeding,  in  this  way,  until  the 
rejected  cone,  which  is  the  base  of  the  tumour,  passes  through  the 
ring  formed  by  the  mouth  of  the  womb.  If  the  parts  should  happen 
to  be  soft  and  dilatable  about  the  root  of  the  tumour,  this  mode  might 
prove  successful;  but  in  opposite  circumstances,  and  such  always 
exist  where  the  accident  is  not  recent,  we  should  only  flatten  the  fun- 
dus without  overcoming  the  strangulation  formed  by  the  mouth  of 
the  organ.  Besides,  we  might  practise  a mixed  method  of  operating, 
that  is  to  say,  we  might  make  the  parts  at  the  root  return  first,  and 
then,  when  the  fundus  alone  remains  inverted,  the  whole  mass  might 
be  pushed  upwards  with  the  tips  of  the  fingers.  Having  the  use  of 
the  hand  alone,  there  never  can  be  any  occasion  for  the  assistance  of 
mechanical  instruments,  as  repel lers,  and  it  will  always  be  found  use- 
less to  employ  a deal  of  force,  and  especially  to  take  a point  d’appui 
against  a wall,  as  was  done  by  an  English  practitioner.*  Having 
procured  the  reduction,  the  hand  is  to  be  left  within  the  womb  until 
contraction  comes  on,  after  which  we  should  proceed,  as  before  di- 
rected, in  speaking  of  reduction  in  incomplete  inversion. 

[I  cannot  think  that  M.  Colombat  gives  the  best  counsel  as  to  the  method 
of  proceeding  for  this  reduction.  It  is  hardly  necessary  to  remark  that  the 
state  of  inversion  does  not  deprive  the  womb  of  its  muscularity,  and  conse- 
quently of  its  ability  to  suffer  what  are  called  after-pains.  It  is  also  well 
known  that  frictions  upon  the  sur-pubal  region,  and  irritations  applied  to  the 
mouth  of  the  womb,  or  the  internal  surface  of  the  organ,  are  constantly  re- 
sorted to  as  means  of  exciting  its  muscular  power.  It  cannot  be,  then,  that 
by  M.  Colombat’s  method  of  grasping  the  neck  of  the  tumour  and  shoving 
it  upwards,  we  could  fail  to  excite  or  irritate  the  organ  into  a violent  exer- 
cise of  its  muscular  force,  which  could  not  exist  without  hardening  the 
tumour  and  rendering  it  stiff  and  inflexible.  But  if  we  render  it  stiff,  hard, 
and  inflexible,  how  shall  we  expect  to  return  it  through  its  hard  and  rigidly 
contracted  os  uteri  ? It  is  manifest  we  cannot  expect  success  by  so  unrea- 
sonable a method  of  operating.  As  the  ancients  used  to  say,  non  cuivis 
contigit  culire  Corinthum , so  I may  say  it  does  not  happen  to  every  prac- 
titioner to  have  reduced  a completely  inverted  womb  ; and  the  late  Prof. 
Dewees  says,  at  p.  512  of  his  System  of  Midwifery , 2d  edit.,  that  “ we 
may  justly  entertain  doubts”  of  the  uterus  having  been  reinstated  after  com- 
plete inversion.  I have  already  spoken,  at  p.  182,  of  the  case  which  I saw 
with  the  late  Prof.  James  and  Dr.  Geo.  Fox,  in  which  the  womb  was  not  only 

* Biblioth.  Medicale,  t.  xlvii.,  p.  271. 


INVERSION  OP  THE  WOMB. 


187 


completely  inverted,  but  had  been  strongly  pulled  by  the  midwife.  Now  in 
that  case,  I used  the  method  recommended  by  Dewees  and  other  authors,  of 
grasping  the  globe  firmly  with  the  hands,  in  the  view  of  pushing  it  back 
bodily  into  the  pelvis — for  it  was  of  enormous  size,  reaching  near  half  way 
to  the  knees — but  I was  unable  to  meet  with  the  least  success,  until  I had 
taken  off  the  placenta,  which  still  adhered,  though  detached  in  certain  parts 
of  the  surface  and  much  torn.  After  I had  removed  the  afterbirth,  I found 
that  the  organ  became  alternately  soft  and  rigid,  just  as  happens  after  de- 
livery in  an  ordinary  labour  ; and  I further  observed  that  to  handle  it  was  to 
irritate  its  contractility  and  to  harden  it,  which  rendered  it  obdurate  against 
every  attempt  at  reduction.  I was  compelled,  therefore,  to  do  what  M. 
Colombat  so  pointedly  condemns  : i.  e.,  to  wait  until  it  became  relaxed,  and 
then  to  indent  the  fundus  and  to  drive  that  cone  through  the  centre  of  the 
globe,  and  up  through  the  cervix  and  os  uteri,  until  I had  carried  my  hand 
so  high  that  the  external  organs  contained  my  arm  not  more  than  four  or 
five  inches  below  the  elbow.  I feel  very  confident  that  if,  in  any  case, 
I could  succeed  in  indenting  a fundus  uteri  and  in  bringing  the  cone  up  to 
the  os  uteri,  I could  always  perfect  the  operation  by  gently  pressing  that 
cone  against  the  ostium  uteri,  which,  under  a persevering  maintenance  of 
the  pressure,  would  yield  as  readily  as  it  does  to  a labour  pain,  or  to  the  cone 
of  the  hand,  when  introduced  in  cases  of  hourglass  contraction  or  spasm  of 
the  cervix  under  encysted  or  retained  placenta.  I dare  recommend  to  the 
reader,  therefore,  to  disregard  the  author’s  injunction  and  to  adopt  the  method 
which  I found  successful. — M.] 

Should  the  pressure  of  the  hand  on  the  womb,  and  the  irritation 
of  the  os  tincse,  together  with  frictions  of  the  hypogaster,  fail  to 
cause  contractions,  and  re-establish  the  tonicity  of  the  organ,  rather 
than  make  use  of  spirituous  and  astringent  injections,  as  recom- 
mended by  some  writers,  among  whom  we  may  mention  Gardien, 
I should  prefer  to  exhibit  a few  grains  of  secale  cornutum,  by  which 
I should  expect,  not  only  to  excite  the  contractions,  but  also  to  arrest 
the  haemorrhage,  which  is  one  of  the  most  serious  phenomena  in 
uterine  inversion.  This  method,  which  has  never  been  attempted 
in  such  cases,  promises  to  fulfil  the  twofold  indication,  and  to  be*unat- 
tended  with  any  inconvenience,  when  prescribed  by  a person  pro- 
perly qualified  for  the  emergency.  Generally  speaking,  there  is  little 
reason  to  fear  a relapse  ; yet  the  womb  has  been  found  to  invert 
itself  afresh,  even  several  days  after  the  reposition  had  been  effected. 
To  obviate  such  an  occurrence,  the  greatest  attention  should  be  paid 
to  the  state  of  the  organ,  and  the  patient  should  be  advised  to  keep 
perfectly  quiet,  and  lie  upon  the  back  for  several  weeks,  carefully 
eschewing  all  sorts  of  exertion  that  might  have  an  injurious  effect 
upon  the  uterus. 

In  the  case  of  an  inversion  of  long  standing,  and  where,  from  the 
contact  of  the  air,  or  strangulation,  or  fruitless  and  violent  efforts  ‘at 
reduction,  the  parts  are  found  to  be  tumefied  and  inflamed,  or  where 


188 


INVERSION  OF  THE  WOMB. 


the  neck  of  the  womb  is  spasmodically  contracted,  we  might  follow 
the  example  of  Lauverjat,  of  Hoin,  and  of  Choppart,  and  divers 
other  practitioners,  which  is  to  combat  all  these  affections  by  means 
of  the  antiphlogistic  remedies,  such  as  blood-letting,  baths,  emollient 
fomentations,  opiates,  &c. : with  a view  to  lessen  the  spasm  of  the 
cervix  uteri,  and  facilitate  its  dilatation,  it  would  be  well  frequently 
to  anoint  the  tumour,  and  the  circle  by  which  it  is  strangulated,  with 
a liniment,  composed  as  follows  : 

— Beurre  de  cacao, 

Olive  oil,  aa  ,fss  ; 

Extr.  belladonnas,  gr.  viij. 

M. — ft.  Liniment. 

When  the  magnitude  of  the  tumour  is  increased  by  the  presence 
within  the  cavity  of  intestinal  convolutions,  they  ought  to  be  pushed 
back  into  the  abdomen,  by  pressing  them  carefully  from  below  up- 
wards, and  obliquely  from  before,  backwards.  Should  the  womb  be 
found  engorged  merely,  and  not  inflamed,  the  advice  of  Dessault,* 
Madame  Boivin,  and  Duges,t  should  be  followed,  to  try  to  lessen  the 
volume  of  the  lower  portions  of  the  tumour,  by  means  of  a steady 
compression  with  a small  bandage,  even  when  the  tumour  does  not 
jut  forth  from  the  orifice  of  the  vagina  This  object  may  be  put- 
sued  by  means  of  a linen  ball  fixed  to  the  cuvette  of  a stem-pessary, 
and  assisting  the  effect  of  this  gentle  and  prolonged  compression  by 
making  friction  over  the  course  of  the  round  ligaments.  It  might  be 
possible  to  effect  a gradual  reduction,  even  where  a prompt  reduc- 
tion was  impracticable,  or  even  contra-indicated. 

Having  well  ascertained  the  impracticability  of  reduction,  and 
that  a continuance  of  the  attempts  could  only  be  productive  of  in- 
jury to  the  patient  by  aggravating  all  the  symptoms,  there  are  left 
in  the  power  of  the  art  no  means  even  of  palliating  the  distressing 
effects  of  the  disease.  Thus,  for  the  relief  of  the  floodings,  prescrip- 
tions have  been  made  of  all  the  various  astringents;  of  the  permanent 
tampon ; of  sponges,  and  a variety  of  means,  that  always  prove  of 
very  small  efficacy  for  these  unfortunate  cases.  Under  such  circum- 
stances, all  that  can  properly  be  done  is,  to  endeavour  to  keep  the 
womb  within  the  walls  of  the  vagina,  by  means  of  a pessary,  so  as 
to  relieve  it  of  the  sort  of  strangulation  to  which  it  is  subject,  when 
pendulous  beyond  the  ostium  vaginae ; and  from  the  mischiev- 
ous impression  of  the  air  upon  its  surface,  as  well  as  those  of  the 
frictions,  and  the  contact  of  the  urine. 

Sometimes  it  happens  that  the  inflammation  of  the  completely  in- 
verted womb  is  resolved,  and  the  organ  remains  irreducible  without 
giving  the  patient  any  great  inconvenience.  Millot,f  in  hopes  of 
relieving  the  patient  of  her  infirmity,  proposes,  for  the  purpose  of 
obtaining  the  reduction  in  such  cases,  that  an  incision  should  be 
made  in  the  cervix  so  as  to  take  off  the  constriction,  by  the  use  of 
Frere  Gome's  lithotome  cache.  This  proceeding,  which  it  seems 
ought  not  to  be  absolutely  rejected  when  all  other  resources  are  vain, 

* Diet,  de  Med.,  t.  xviii.  t.  276.  f Mai.  de  1’Uterus,  t.  i.  p.  238. 

4 Supplement  a tous  les  Trails  sur  les  Accoachements,  1773. 


INVERSION  OF  THE  WOMB. 


1S9 


would,  we  think,  be  much  more  efficacious  and  certain,  if,  instead  of 
a simple  incision,  which  to  do  any  good,  ought  to  be  carried  to  a 
dangerous  length,  the  constriction  of  the  cervix  should  be  removed 
by  means  of  four  small  incisions,  made  in  an  oblique  direction  from 
the  centre  towards  the  circumference,  ‘either  with  a probe-pointed 
bistoury,  or  what  is  still  better,  a small  lancet,  with  a concave  probe- 
pointed  blade,  invented  by  the  author  for  operating  in  fistula  in  ano, 
and  for  cutting  the  stricture  in  strangulated  hernia.  Even  should 
these  four  incisions  amount  to  only  half  a line  each,  a greater  dilata- 
tion would  be  procured  by  them  than  from  a single  incision  of  four 
or  five  lines  ; for  with  such  an  one,  the  relaxation  could  only  interest 
one  point  of  the  cervical  ring,  whereas,  by  the  multiple  incisions, 
the  circumference  of  the  os  tineas  would  be  enlarged  throughout. 
From  these  purely  geometrical  data,  we  may  clearly  perceive  that  the 
multiple  incision,  which  need  not  be  extensive,  would  be  less  liable  to 
induce  lacerations  upon  pushing  up  the  fundus  uteri  through  the  os 
tineas,  a single  long  incision  of  which  would  be  both  hazardous  and, 
at  the  same  time,  insufficient  for  the  object  proposed.* 

When  reduction  cannot  be  obtained,  it  now  and  then  happens  that 
the  disease  ends  in  gangrene.  In  such  event  the  suppuration  should 
be  promoted  with  the  view  to  produce  the  separation  of  the  eschars, 
while  we  also  try  to  allay  the  symptoms  by  tonic  drinks  and  by 
injections  and  fomentations  with  cinchona,  camphor,  chloride  of 
sodium,  &c.  But  should  the  symptoms  be  so  severe  as  to  threaten 
the  woman  with  inevitable  death,  let  the  womb  be  removed  either 
by  the  ligature  or  by  a direct  amputation. 

There  are  numerous  cases  to  show  that  this  last  plank  of  safety 
has  not  been  trusted  to  in  vain.  Carpue,  Osiandert  and  Wrisbergf 
have  related  cases  of  the  completely  inverted  womb,  the  extirpation 
of  which  has  been  described.  The  ligature  which  has  most  com- 
monly been  employed  has  met  with  success.  Rousset§  has  published 
two  cases.  Faivre,||  Bouchet,  sen.,  of  Lyons,!  Newnham,**  Gran- 
ville and  Gooch, tt  Windsor, Johnson, §§  Chevalier, ||||  and  others 
have  reported  facts  of  the  same  kind,  the  authority  of  which  cannot 
be  questioned. 

It  is  true  that  to  all  these  instances  of  success  we  may  oppose  a 
great  array  of  cases  in  which  the  extirpation  has  been  followed  by 
the  death  of  the  woman.  For  example,  the  patient  operated  on  by 
Deleurye,!!  died  in  the  course  of  a few  days ; and,  in  another  case, 

* In  our  memoir  on  la  Cystotomie  sous  pubienne  quadrilaterale,  1831,  we  dwelt  in 
much  detail  on  the  advantages  of  multiple  incisions  to  take  off*  stricture  where  the 
object  is  to  obtain  a free  opening  without  making  extensive  wounds. 

f Neue  Denkwurdigkeiten,  b.  i.  312.  4 De  Uteri  Resectione,  &c.  Gott.,  1787. 

§ Traite  de  l’Operat.  Caesar,  354.  |j  Jour,  de  Med.,  Aug.,  1786. 

*j[  Collect,  de  la  Soc.  Med.  de  Lyons,  t.  i. 

**  On  the  symptoms,  &c.,  with  a history  of  the  successful  extirpation  of  the  uterus, 

p.  82. 

ff  Lond.  Med.  & Surg.  Jour.,  1828.  **  Med.  Chir.  Trans.,  x.  361. 

§§  Dub.  Hosp.  Rep.,  iii. 

jlU  Traite  de  Mai.  de  l’Uterus,  by  Boivin  and  Duges,  i.  240. 

Precis  des  Legons  de  Baudelocque  sur  les  Renversemets  de  la  Matrice,  par 

Daillez,  104. 


190 


ELEVATION  OF  THE  WOMB. 


the  woman  died  in  seventeen  days  after  the  application  of  a ligature 
upon  the  root  of  an  inverted  womb  that  was  mistaken  for  a polypus 
uteri,  and  in  which  a post-mortem  examination  confirmed  the  diag- 
nosis that  had  been  given  by  Goulard  before  the  performance  of  the 
operation.  Under  similar  circumstances  Baudelocque  and  Desault 
were  equally  unfortunate  ; and,  in  fact,  the  application  of  the  ligature 
to  the  inverted  womb,  supposed  to  be  merely  polypus  uteri,  was,  in 
two  other  cases,  followed  by  death — one  of  these  cases  being  under 
the  care  of  Dr.  Rey,  and  operated  on  at  Lyons  in  presence  of  Marc 
Antoine  Petit,  and  the  other  at  Paris,  where  the  operation,  which  was 
done  by  a young  surgeon,  terminated  fatally  in  a few  days,  though 
the  first  symptoms  were  not  so  very  rapid,  and  though  the  organ  was 
really  thrown  off  by  gangrene.*  M.  Dugest  states,  that  in  a woman 
lying  under  imminent  danger  of  death,  Baron  Dubois  endeavoured  to 
strangulate  the  uterus  by  a ligature,  which  put  a stop  to  the  flooding, 
but  the  distinguished  professor  was  soon  compelled,  by  the  occurrence 
of  alarming  symptoms,  to  remove  the  thread  which  he  had  cast  on 
the  neck  of  the  tumour.  Be  this  as  it  may,  the  single  ligature,  as 
used  by  the  surgeons  above  mentioned,  or  even  the  double  one,  ad- 
justed by  passing  a needle  through  the  middle  of  the  neck,  as  was 
done  in  Baxter’s!  case,  are  the  extreme  resorts  to  which  we  must 
always  turn  where  no  other  chance  remains  of  prolonging  the  life  of 
the  patient. 

Previously  to  closing  our  remarks  upon  the  treatment  of  inversion 
of  the  womb,  we  must  add  that  those  cases  that  are  produced  by  the 
weight  of  a polypus,  or  that  are  voluntarily  brought  on  for  the  pur- 
pose of  facilitating  an  operation,  almost  always  reduce  themselves 
spontaneously,  as  soon  as  the  cause  that  produced  them  is  with- 
drawn. 

OF  THE  ELEVATION  OF  THE  WOMB. 

In  some  rare  cases  the  uterus  becomes  so  highly  elevated  above  the 
excavation  of  the  pelvis,  that  the  os  tincae  becomes  almost  inaccessi- 
ble to  the  Touch , and  it  is  wholly  impossible  to  reach  the  posterior 
surface  of  the  womb  by  the  Touch  from  the  rectum. 

The  ascension  of  the  womb,  which  is  rare  in  its  non-gravid  con- 
dition, may  arise  from  a variety  of  causes;  such  as  insufficient  length 
and  width  of  the  ligaments;  the  formation  of  an  abscess  within  these 
ligaments ; inflammation,  engorgement  and  dropsy  of  the  tubes  and 
the  ovaries;  an  exfra-uterine  pregnancy;  the  first  stage  of  antever- 
sion  and  retroversion;  and,  lastly,  the  expansion  of  the  uterine  cavity 
by  hydatids  or  other  foreign  bodies. 

As  the  upward  displacement  of  the  womb  in  pregnancy  is,  in 
some  sort,  a normal  effect  of  that  condition  from  the  fourth  to  the 
eighth  month,  it  does  not  deserve  any  special  attention,  except  as  it 
is  taken  as  a sign  of  several  kinds  of  disorder.  As  alone  consi- 
dered, it  generally  causes  no  sort  of  inconvenience,  there  will  be  no 

* Boyer,  t.  x.  510.  j-  Traite  des  Mai.  de  l’Uter.,  loc.  cit. 

t Annale  de  la  Litterat.  Med.  Etrang.,  t.  xv.  578 


IMMOBILITY  OF  THE  WOMB. 


191 


reason  (o  feel  uneasy  about  it,  except  in  view  of  the  causes  that  may 
have  led  to  its  existence ; and  it  of  course  requires  no  treatment  but 
that  applicable  to  the  disorders  of  which  it  is  a symptom.  Besides, 
where  the  elevated  state  of  the  uterus  is  a permanent  one,  as  when 
it  results  from  the  faulty  state  of  the  broad  ligaments,  it  may  act  as 
a cause  of  barrenness.  It  might  be  possible  to  overcome  it  by  ap- 
plying by  means  of  a speculum,  a small  cupping-glass,  with  exhaust- 
ing pump,  to  the  cervix  uteri,  and  leaving  it  in  situ  a few  minutes; 
the  operation  to  be  repeated  from  time  to  time,  so  as  not  to  fatigue 
the  woman  too  much.  And,  lastly,  to  promote  the  relaxation  of  the 
uterine  ligaments  and  modify  their  recent  adhesions  and  retractions, 
recourse  ought  to  be  had  to  baths  and  to  frictions  with  mercurial  oint- 
ment, a drachm  each  time  being  rubbed  in  upon  the  hypogastric  and 
iliac  regions  of  the  abdomen. 

OF  ABNORMAL  IMMOBILITY  OF  THE  WOMB. 

While  too  great  a degree  of  mobility  of  the  womb  is  productive  of 
various  displacements,  rendering  the  patient  liable  to  very  serious  dis- 
orders, the  absolute  immobility  of  the  organ,  in  addition  to  the  ob- 
struction it  causes  as  to  the  dilatation  of  the  bladder  and  rectum, 
might  give  rise  to  other  inconveniences  still  more  serious  on  account 
of  their  greater  frequency. 

Among  the  causes  of  immobility  of  the  womb,  may  be  enume- 
rated those  adhesions  that  follow  attacks  of  peritonitis,  or  inflamma- 
tion of  the  other  organs  in  the  vicinity  of  the  womb  and  its  append- 
ages, such  as  the  rectum  and  the  bladder. 

Attacks  of  metritis  and  metroperitonitis*  succeeding  laborious  par- 
turition, or  difficult  menstruation,  also  give  rise  to  morbid  adhesions 
and  to  unnatural  ligaments,  which  often  attach  themselves  to  the 
womb  as  well  as  the  sides  of  the  pelvis,  yet  remain  undetected  long 
after  their  formation. 

Adhesions  producing  immobility  of  the  uterus  were  not  properly 
understood  until  since  the  publication  of  Madame  Boivin’st  re- 
searches upon  one  of  the  most  common  causes  of  abortion.  The 
author  of  that  important  work,  and  also  M.  Duges,f  have  remarked 

* Dr.  Veindmann,  in  1818,  published  a memoir  (Casus  Rari)  containing  a descrip- 
tion and  drawing  of  an  adhesion  of  the  epiploon  to  the  anterior  surface  of  the  womb, 
which  was  probably  the  consequence  of  an  attack  of  puerperal  metro-peritonitis.  In 
her  subsequent  pregnancy  she  died  at  the  fifth  month,  with  all  the  symptoms  of  an 
internal  strangulation. 

[I  lost  a patient,  a married  lady,  of  about  thirty-two  astat.,  two  years  since,  with 
strangulated  intestine,  which  had  strangulated  itself  under  an  abnormal  ligament  in 
the  lower  part  of  the  pelvis  behind  the  womb.  This  ligament  must  have  been  formed 
when  she  was  about  twelve  years  of  age:  at  which  time  she  suffered  a dangerous 
and  nearly  fatal  attack  of  peritonitis.  She  had  all  the  symptoms  of  iliac  passion, 
and  it  was  not  till  after  death  that  the  strangulation  was  ascertained  to  take  place  in 
the  pelvis. — M.] 

f Recherches  sur  les  causes  les  plus,  frequentes  de  I’Abortement. 

* Traite  Prat,  des  Mai.  de  l’Uterus,  t.  i.  p.  176. 


192 


IMMOBILITY  OF  THE  WOMB. 


that  scrofulous  women,  and  those  who  possess  a lymphatic  tempera- 
ment ; those  who  are  subject  to  constipation  and  irregular  action  of 
the  digestive  apparatus,  are  also  more  liable  than  others  to  unnatural 
adhesions,  and  by  consequence,  to  preternatural  immobility  of  the 
organ.  It  would  seem,  from  what  M.  Duges  has  observed,  that  little 
girls  abandoned  to  habits  of  masturbation  are  also  liable  to  this  sort  of 
immobility  ; for  the  permanent  excitement  of  their  genital  organs  by 
sympathetically  irritating  the  peritoneum,  and  particularly  that  part 
of  it  connected  with  the  womb,  must  necessarily  lay  the  foundation 
of  adhesions  betwixt  the  womb  and  the  other  peritoneal  superficies. 
These  opinions,  which,  however,  as  M.  Duges  says,  are  as  yet  merely 
conjectural,  require,  for  their  confirmation,  the  careful  observation  of 
many  cases. 

By  means  of  the  Touch  per  vaginam , and  by  learning  the  past 
history  of  the  case,  it  is  within  our  power  to  foresee  that  a certain 
degree  of  this  uterine  immobility  may  render  it  impossible  for  the 
womb  to  rise  upwards  properly  in  the  gravid  state.  By  the  intro- 
duction of  the  finger  we  discover  that  the  womb  is  firmly  fixed  to 
one  side  according  to  the  direction  it  has  taken.  In  some  instances 
it  seems  to  be  confined  in  every  direction  around  it ; in  others,  only 
at  certain  points  of  its  circumference. 

Where  the  womb  rises  higher  on  one  side  than  on  the  other,  it 
is  because  one  of  the  round  ligaments  has  become  engorged  and 
shortened,  so  that,  at  the  sixth  or  seventh  month  of  gestation,  it  is 
almost  inevitable  for  the  woman  to  abort,  as  Madame  Boivin  has 
shown  by  many  examples. 

The  historical  circumstances  that  may  serve  to  throw  light  on  the 
diagnosis,  are  certain  maladies,  such  as  inflammations  of  the  womb 
and  the  peritoneum,  dysentery,  abortions,  laborious  labours,  and  a 
variety  of  physical  lesions,  such  as  wounds,  lacerations,  and  abscesses 
in  the  uterus  and  the  tissues  adjacent  to  it. 

Although  sterility,  that  is  often  caused  by  the  adhesion  of  the  Fallo- 
pian tubes,  is  to  be  regarded  as  a misfortune,  conception, in  such  a con- 
dition, is  a vastly  more  serious  one,  since  it  may  give  rise  to  the  most 
important  symptoms,  by  setting  on  foot  a new  inflammation,  caused 
by  the  stretching  of  the  ligaments  of  the  expanding  womb,  as  it  con- 
tinues to  rise  higher  and  higher  during  the  pregnancy.  This  gives 
the  woman  violent  pain,  and  dragging  in  the  pelvis,  and  a feeling  of 
lassitude  in  the  thighs.  Abscesses  often  form  in  the  vagina  and  rec- 
tum, and  in  most  cases,  the  death  of  the  patient,  which  is  inevitable, 
is  preceded  by  abortion,  which  may  be  expected,  about  the  third  or 
fourth  month,  upon  some  attack  of  violent  uterine  inflammation  or 
profuse  haemorrhage. 

While,  on  the  one  hand,  these  preternatural  adhesions  may  tie  up 
the  non-gravid  uterus,  while  of  its  natural  dimensions  and  in  its  pro- 
per situation,  so  on  the  other,  may  similar  accidental  causes  operate 
while  the  organ  is  very  high  up  in  the  abdomen,  and  distended  with 
the  products  of  conception.  In  some  cases,  the  omentum,  jammed 
far  up  in  the  epigastric  region,  inflames  at  a point  in  contact  with 
the  womb,  aiid  then  very  readily  forms  adhesive  connections  with  it. 


IMMOBILITY  OF  THE  WOMB. 


193 


This  pathological  soldoring  is  in  general  productive  of  no  inconveni- 
ence, and  is  not  disclosed  by  any  symptom  during  the  progress  of  the 
pregnancy  ;*  but  the  case  is  different  where  the  womb,  become  freed 
from  the  products  of  conception,  returns  rapidly  towards  its  non-gra- 
vid  dimensions,  descending  from  the  epigastrium  down  behind  the 
symphysis  of  the  pubis.  The  omentum,  now  become  too  short  from 
its  accidentally  rolled  condition,  is  powerfully  and  painfully  stretched ; 
unless,  indeed,  the  adhesions  and  unnatural  bands  that  bind  the  womb 
happen  to  be  weak  enough  to  break  and  set  it  free.  This  perito- 
neal tension,  and  the  retractive  movement  of  the  uterus  detained 
thereby  above  the  superior  strait,  are  recognized  by  the  following 
symptoms  : the  colon  and  stomach  are  painfully  dragged  downwards, 
and  their  irritation  is  participated  in  by  the  peritoneum,  which  in- 
flames from  partial  ruptures  or  lacerations  taking  place  at  different 
points  of  its  surface,  upon  which  supervene  attacks  of  vomiting,  diar- 
rhoea, fainting,  &c.  Lastly,  should  the  adhesions  not  give  way,  there 
is  almost  always  an  attack  of  fatal  haemorrhage,  brought  on  in  con- 
sequence of  the  inability  of  the  womb  to  contract  to  its  proper  size 
again,  thus  preventing  the  great  sinuses  of  the  organ  from  closing, 
and  leaving  their  orifices  so  open  as  to  permit  a large  issue  of  blood. 
Samples  of  this  sort  are  to  be  found  in  Madame  Lachapelle’st  excel- 
lent work.  Fred.  Ruysch,f  as  well  as  the  celebrated  Morgagni, § has 
published  cases  of  the  same  kind,  but  of  a less  distressing  result,  for 
they  merely  gave  rise  to  the  painful  dragging  of  the  stomach,  and 
some  other  derangements  of  the  health. 

Unfortunately,  the  physician,  after  ascertaining  the  existence  of 
the  adhesions  in  question,  is  compelled  to  remain  merely  a sad  spec- 
tator of  the  disorders  arising  from  them.  The  sole  resource  we  have 
is  to  endeavour  to  prevent  the  adhesions,  and  the  formation  of  the 
bands  that  fix  the  uterus  in  an  immovable  station.  This  attempt 
may  be  made  by  the  employment  of  antiphlogistic  means,  to  which 
should  be  added  the  use  of  mercurial  frictions  upon  the  abdomen. 
Having  overcome  the  inflammation  that  has  produced  the  attach- 
ment, there  is  some  probability  of  effecting  the  resolution  of  such 
adhesions  as  have  not  become  consolidated,  and  putting  a stop  to 
the  pathological  action  which  tends  to  their  production.  In  their 
work  upon  the  diseases  of  the  uterus,  Madame  Boivin  and  M.  Duges 
have  published  a case  of  adhesion  of  the  uterine  appendages,  accom- 
panied with  symptoms  of  chronic  inflammation,  that  was  cured  by 
means  of  a mercurial  treatment.  The  mercurial  ointment  was  ex- 
hibited in  friction  on  the  thighs  and  sides  of  the  abdomen,  a drachm 
at  each  friction.  In  the  course  of  one  month,  all  the  symptoms  dis- 
appeared, without  the  occurrence  of  salivation.  After  six  months 

* It  is  true,Baudelocque  had  a case  which  proved  fatal  before  delivery,  in  the  first 
stage  of  labour,  where  the  epiploon  was  rolled  up  like  a rope  and  attached  to  the  right 
lateral  anterior  part  of  the  womb,  so  that  the  stomach  and  arch  of  the  colon  were 
singularly  pulled  by  it.  The  fatal  termination  was  preceded  by  vomiting,  diarrhoea 
and  syncope.  Traite  des  Mai.  de  I’Uterus,  par  Boivin  and  Duges. 

f Prat,  des  Accouch.,  ou  M6m.  et  Obs.,  t.  ii.,  p.  376. 

* Obs.  Anat.  Chir.  Centur.,  p.  59  and  78.  § Epistol.  Anatom.,  46,  art.  46. 

13 


194 


HYSTEROCELE. 


the  woman  could  scarcely  be  recognized  as  the  same  person,  so  great 
was  the  change  in  her  appearance.  The  authors  prefaced  this  case 
with  the  history  of  other  cases  of  immobility  of  the  womb  in  preg- 
nant women,  all  of  which  produced  abortion  and  death  between  the 
third  and  fifth  month  of  pregnancy. 

OF  HYSTEROCELE  OR  HERNIA  OF  THE  WOMB. 

Notwithstanding  hernia  of  the  womb  is  very  rare,  the  annals  of 
medicine  contain  a sufficient  number  of  cases  to  prove,  beyond  cavil, 
that  such  an  occurrence  is  possible,  not  only  in  the  non-gravid,  but 
also  in  the  gravid  womb. 

Though  in  general  the  womb  does  not,  except  in  pregnancy,  rise 
above  the  superior  strait,  hysterocele  has  been  noticed  in  several  in- 
stances, of  which  we  shall  speak  presently,  by  Choppart,*  by  Prof. 
Lallement,t  and  by  Dr.  Murat. f 

The  principal  characters  of  hysterocele  in  the  non-gravid  womb 
are  the  following : the  tumour  is  hard,  very  little  reducible,  and 
mostly  indolent ; its  form  is  roundish,  and  its  root  is  thick ; the  vagina 
is  stretched,  and  curved  obliquely  from  below  upwards  towards  one 
of  the  groins.  The  os  uteri,  which  is  very  high  up  in  the  pelvis,  is 
pointed  towards  the  sacrum ; or  it  wholly  disappears,  having  been 
lodged  within  the  hernial  tumour.  The  reduction,  which  ought  to 
be  promptly  attempted,  with  the  greatest  care,  cannot  be  effected, 
except  when  the  hysterocele  is  a recent  one,  of  small  size,  and  with- 
out any  adhesions.  After  the  reduction,  a relapse  should  be  pre- 
vented by  a large  compress  of  lint,  supported  by  a bandage. 

[A  common  truss  for  inguinal  hernia  would  be  preferable. — M.] 

While  hernia  of  the  non-gravid  uterus  is  liable  to  be  confounded 
with  protrusion  of  other  abdominal  viscera,  such  a mistake  cannot 
be  made  as  to  that  of  the  pregnant  womb. 

In  fact,  the  volume  of  the  tumour,  which  daily  increases,  the  dull 
fluctuation  perceptible  in  it,  the  motions  of  the  foetus  that  are  dis- 
tinguishable through  the  integuments,  and  the  sounds  of  the  foetal 
heart,  ascertained  by  the  stethoscope,  yield  so  many  signs,  that  afford 
a sure  diagnosis,  and  remove  every  remaining  doubt  as  to  the  nature 
of  the  hernia. 

There  are  three  kinds  of  hysterocele,  which  are : 1.  Inguinal, 
never  met  with,  except  in  the  non-gravid  state.  2.  Crural , which 
may  occur  in  that  state,  but  most  commonly  in  the  pregnant  female  ; 
and  3.  Ventral , which  may  take  place  where  the  womb  is  distended 
with  the  products  of  a conception. 

From  a case  published  by  Maret,§  formerly  perpetual  Secretary  to 
the  Academy  of  Sciences  at  Dijon,  it  appears  to  be  possible  for  an 
inguinal  hysterocele  to  be  congenital.  In  the  instance  spoken  of  by 

* Boyer.  Mai.  Chirurg.,  t.  viii.  p.  381. 

-J-  Mem.  de  la  Soc.  Med.  d’Emulation,  3 ann.  323. 

i Diet,  de  Med.,  en.  21  vol.,  t.  ii.  p.  162. 

§ Consultations  Med.,  Legates:  and  Mad.  Boivin  and  M.  Duges,  t.  i.  p.  39. 


HYSTEROCELE. 


195 


this  learned  observer,  the  hernia  of  the  womb  was  upon  the  right 
side,  which  is  the  most  common  situation  of  inguinal  hernia  uteri ; 
probably  because  the  womb  is  naturally  somewhat  inclined  towards 
that  side,  and  because  the  round  ligament  on  that  side  is  shorter  than 
its  fellow,  and  thicker. 

The  causes  of  hysterocele  in  pregnancy  may  be  attributed  to 
weakness,  or  relaxation  of  the  ligaments  of  the  womb ; to  a violent 
blow  and  contusion  of  the  belly  ;*  to  the  effects  of  a Caesarian  opera- 
tion in  a preceding  labour ;t  and  it  should  be  considered  that  an 
abscess  in  the  groinf  or  hypogaster,  a sudden  separation  of  the  linea 
alba,§  an  old  cicatrix,  and  certain  other  lesions,  like  those  we  have 
just  named,  may  give  rise  to  hysterocele  upon  the  occurrence  of  some 
violent  shock  or  effort  of  the  patient. 

As  these  displacements  are  very  rare,  we  shall  confine  ourselves 
to  the  relation  of  a few  of  the  cases  of  each  sort  that  are  contained 
in  the  records  of  the  science. 

1 

INGUINAL  HYSTEROCELE. 

A case  of  this  kind  of  hysterocele,  which  most  writers  look  upon 
as  impossible  in  pregnancy,  was  met  with  by  Professor  Lalle merit, || 
at  the  Hospital  la  Salpetriere,  in  a woman  at  the  age  of  seventy-one 
years.  The  tumour,  which  had  come  through  the  right  inguinal  ring, 
contained  the  right  ovary,  the  whole  of  the  womb,  and  a portion  of 
the  vagina : the  hard  life  led  by  this  woman  had  given  rise  to  and 
caused  the  gradual  increase  of  the  tumour,  which,  though  very  pain- 
ful at  first,  gradually  became  indolent.  It  was  pear-shaped,  and  four 
or  five  finger-breadths  long.  Professor  BoyerTT  gives  the  analysis 
of  a case  of  the  same  nature,  published  by  Choppart : the  woman 
was  fifty  years  of  age  ; her  worrlb,  which  almost  completely  escaped 
through  the  inguinal  ring,  along  with  the  left  ovary  and  tube,  was 
contained,  without  any  adhesions,  in  a very  large  hernial  sac,  and 
appeared  to  be  much  smaller  than  common.  It  was  of  an  oblong 
shape,  of  a pale  red  colour,  a soft  and  flaccid  consistence.  It  was 
constricted  near  the  place  of  the  ring ; and  exhibited  at  the  fundus 
some  membranous  laminae  that  seemed  to  be  the  result  of  a former 
adhesion  of  the  epiploon. 

CRURAL  HYSTEROCELE. 

Crural  hysterocele  may  also  occur  in  the  non-gravid  state  of  the 
womb.  M.  Murat**  and  Professor  Lallementf  ±*saw  a case  of  the 
kind  in  a woman  eighty-two  years  of  age,  who  died  at  la  Salpetriere 

* Dan.  Sennertus,  Opera  Omnia,  de  Hernia  Uterina,  tom.  iii.  p.  654. 
t Rousset,  Traite  de  l’Oper.  Cesar.,  loc.  cit. 
t Ruysch,  Advers.  Anat.  Chir.  Med.  Decas  ii.  23. 

§ J.  L.  Petit,  CEuvres  Posthumes,  t.  iii.  p.  264. 

||  Mem.  de  la  Soc.  d’Emulation,  iii.annee  323. 

T[  Boyer,  Maladies  Chirurg.,  t.  viii.  381. 

**  Diet,  de  Med.  in  21  vol.,  v.  iii.  p.  162. 

•j-f  Bulletins  de  la  Faculte  de  Med.  de  Paris,  t.  i.  p.  1.  1816. 


196 


CRURAL  HYSTEROCELE. 


in  1816.  She  had  had  the  hernial  tumour  for  forty  years;  it  was 
five  inches  long  and  four  in  width,  and  occupied  the  whole  bend  of 
the  right  groin.  It.  was  of  a pyramidal  shape,  the  apex  above  and 
the  base  downwards.  Upon  a careful  dissection,  it  was  found  that 
the  hernial  protrusion  had  taken  place  behind  the  broad  ligament, 
and  that  the  tumour  contained  the  womb,  the  ovaries,  the  tubes,  and 
a portion  of  the  vagina.  This  kind  of  hernia  also  takes  place  in  the 
pregnant  womb.  Fabricius  Hildanus*  cites  from  Doering, t that  a 
woman  of  Nissa,  in  Silesia,  at  the  period  in  her  ninth  pregnancy,  had 
a tumour  in  the  left  groin  which  grew  so  as  to  extend  down  to  her 
khee.  Upon  a consultation  of  physicians  being  held,  it  was  decided 
that  an  incision  should  be  made  into  the  middle  of  the  tumour,  to  ter- 
minate the  labour  deemed  by  all  other  means  impracticable.  A child 
was  extracted,  that  lived  several  months  ; hut  the  mother  died  in  the 
course  of  three  days,  after  having  suffered  the  most  excruciating 
pain. 

The  celebrated  Daniel  Sennertus,±  who  died  with  the  plague  at 
Wittemburg,  in  1637,  states  that  the  wife  of  a cooper,  in  the  early 
stage  of  her  pregnancy,  being  busy  helping  her  husband  to  bend 
some  hoop-poles,  one  of  them  suddenly  sprung  back  and  struck  her 
a violent  blow  on  the  left  groin.  Immediately  after  the  accident  a 
tumour  appeared  upon  the  part,  which  increased  daily  in  size,  until 
it  became  too  large  to  be  reduced  ; and  the  patient  was  under  the 
necessity  of  supporting  it  by  a suspensory  bandage  from  the  shoul- 
ders. The  term  of  pregnancy  being  at  length  come,  the  Caesarian 
operation  was  performed  upon  the  tumour.  The  promising  hopes  of 
success  that  followed  the  operation  were  not,  however,  sustained,  as 
she  died  on  the  twentieth  day,  though  the  child  lived  for  nine  years. 
Although  it  is  probable  that  both  this  and  the  case  from  Hildanus 
were  crural  hernia  uteri,  yet  the  few  details  given  leave  some  doubt 
as  to  that  point ; and  it  is  possible,  that  in  this  case  the  tumour  may 
have  been  formed  through  the  inguinal  ring,  or,  what  is  more  pro- 
bable, through  a rupture  of  the  muscles  of  the  inguinal  region. 


VENTRAL  HYSTEROCELE. 

A ventral  hysterocele  is  one  that  takes  place  through  an  accidental 
separation  of  the  abdominal  muscles.  No  cases  of  this  sort  have 
been  met  with  except  during  pregnancy ; and  it  appears  to  have  been 
often  confounded  with  obliquity  of  the  womb  from  excessive  relaxa- 
tion of  the  abdominal  parietes,  carried  to  such  an  extent  as  even  to 
allow  the  womb  to  fall  over  upon  the  front  part  of  the  thighs.  J/L. 
Petit§  informs  us  that  a woman  who  had  been  in  labour  for  three 
days,  suddenly  felt  a violent  pain,  accompanied  with  a feeling  of  lace- 
ration, in  the  belly,  followed  by  extreme  weakness,  and  a complete 
inertia  of  the  womb.  There  were  two  hernias  of  the  belly.  One 

* De  nova  rara  et  admiranda  hernia  uterina  (Opera.  Omnia,  p.  893). 
f De  Hernia  Uterina  atque  partus  Coesarei  Historia. 
t Opera  Omnia  de  Hernia  Uterina,  t.  iii.  p.  654. 

§ CEuvres  Posthunaes,  t.  iii.  p.264. 


VENTRAL  HYSTEROCELE. 


197 


extended  from  the  umbilicus  t-o  the  symphysis  pubis,  and  the  other 
from  the  navel  to  the  xiphoid  cartilage.  “ The  former,  that  is, 
the  lower  one,  was  so  large  that  the  recti  muscles  were  separated 
from  each  other  to  the  distance  of  nine  or  ten  inches.  I was  told 
that  this  tumour  had  commenced  long  ago,  and  had  increased  with 
each  successive  pregnancy  and  labour ; that  for  the  last  six  months 
the  growth  of  the  tumour  had  been  more  rapid  and  greater,  but  had 
only  attained  its  present  enormous  size  in  the  course  of  the  last  three 
days.”  Petit,  having  ascertained  that  the  foetus  was  hydrocephalic, 
punctured  the  cranium  with  a bistoury,  and  took  measures,  at  the 
same  time,  to  compress  the  abdomen  with  a small  pillow,  secured 
by  a bandage.  The  extraction  was  easily  performed,  and  the  woman 
recovered  promptly.  Frederick  Ruysch*  tells  us  that  a woman  who 
became  pregnant  after  having  had  a suppuration  in  the  groin,  found 
a tumour  forming  in  the  part,  that  grew  so  large  as  to  reach  down  to 
the  knee.  The  time  for  her  confinement  having  arrived,  the  midwife 
succeeded  in  making  the  child  return  into  the  abdomen,  by  lifting  the 
tumour  up,  after  which  it  was  soon  born  by  the  natural  passages. 
Roussett  mentions  a case  of  hernia  of  the  same  kind,  in  a woman 
who  had  undergone  the  Cesarian  operation  in  a preceding  preg- 
nancy. 

We  shall  cite  one  more  case  of  ventral  hysterocele,that  might  readily 
have  been  mistaken  for  a case  of  crural  hernia,  had  it  not  been  sub- 
jected to  a very  careful  examination.  A woman,  forty  years  of  age, 
in  her  fifth  pregnancy,  noticed  the  gradual  increase  of  a tumour 
that  she  had  had  for  some  years  in  the  groin.  It  was  soon  evident 
that  the  tumour  contained  not  only  the  womb,  but  also  a living  foetus. 
Professor  Saxtorph,  the  physician  to  the  patient,  trusted  the  expul- 
sion of  the  child  to  the  mere  powers  of  nature,  but  he  had  to  take 
away  the  placenta,  by  the  introduction  of  his  hand,  which  enabled 
him  to  verify  the  abnormal  situation  of  the  womb.  The  patient  reco- 
vered, notwithstanding  that  her  womb,  after  resuming  its  non-gra- 
vid  dimensions,  continued  to  project  beyond  the  abdominal  parietes, 
which  showed  that  the  protrusion  had  taken  place  through  a division 
in  the  muscles,  and  not  through  a natural  opening,  as  seemed  most 
probable.;]: 

We  shall  not  extend  our  remarks  upon  uterine  hernia  any  fur- 
ther;— merely  adding,  that  the  treatment , whether  in  the  gravid  or 
the  non-pregnant  female,  consists  in  attempting  the  reduction,  and 
the  keeping  the  tumour  reduced,  by  means  of  a suitable  bandage. 
Should  the  reduction  be  found  to  be  impossible,  and  particularly 
where  the  woman  is  beyond  the  child-bearing  age,  we  ought  to  be 
satisfied  with  the  application  of  a containing  bandage.  Under  other 
circumstances,  recourse  ought  to  be  had  to  a gradual  compression 
long  continued,  as  advised  by  J.  L.  Petit  for  adherent  enterocele. 

In  a case  of  pregnant  hysterocele,  where  the  powers  of  labour 
should  appear  to  be  sufficient  for  the  delivery,  as  might  be  supposed 
from  the  regular  progress  of  the  labour,  the  discharge  of  the  waters, 


* Advers.  Anat.  Chir.  Med.  Dec.  ii.,  p.  25.  f Traite  de  1 Oper.  Cesar.,  loc.  cit. 

* Bib.  Med.,  t.  67.  p.  59. 


198 


HERNIA  OF  THE  OVARY. 


and  the  natural  presentation  of  the  foetus  in  the 
vagina,  we  should  do  nothing  more  than  lift  up  and 
support  the  fundus  of  the  womb,  so  as  to  give  to  the 
organ,  as  far  as  possible,  the  direction  it  ought  to  have 
in  a natural  case  of  parturition.  In  other  and  less 
favourable  circumstances,  we  must  have  recourse  to 
the  Caesarian  operation,  which,  notwithstanding  all  the 
dangers  accompanying  it,  succeeded  in  the  woman 
whose  case  we  have  cited  from  Rousset.  In  all  such 
cases  no  decision  should  be  made  in  favour  of  a re- 
sort to  extreme  measures  until  after  the  trial  of  all  the 
others.  Lastly,  should  there  be  observed,  in  a case  of 
hysterocele,  signs  of  a strangulation  of  the  tumour,  it 
should  be  freed  in  the  common  way,  by  cutting  the 
stricturing  edge,  or,  what  is  better,  by  short  multiple 
incisions  with  a probe-pointed  bistoury,  or  the  small 
sound  with  a concealed  blade,  invented  by  us  for 
operating  on  fistula  ano,  and  for  the  multiple  incisions 
of  the  stricture  in  all  forms  of  hernia.  [See  the  Figure 
annexed.) 

HERNIA  OF  THE  OVARY.  7 

Soranus  of  Ephesus,  surnamed  the  Second , to  distinguish  him  from 
the  other  Soranus  of  the  Methodical  sect,  was  the  first  author  to 
mention  hernia  of  the  ovary,  in  his  treatise  on  diseases  of  women, 
a fragment  of  which  was  published  by  Adrian  Turnebus,  under  the 
title,  Be  Utero  et  Muliebri  Pudendo  libellus , some  extracts  from 
which  are  also  given  by  Oribasius  and  Aetius.  Describing  a sort  of 
hernia  that  he  thought  very  extraordinary,  he  says,  that  “ the  intes- 
tines had  fallen  down  into  the  labia , or,  according  to  his  expression, 
into  the  scrotum,  preceded  by  the  ovaries.”* 

Verdiert  met  with  a similar  instance  fifteen  centuries  after  Sora- 
nus ; Hallerf  gave  a third,  and  Percival  Pott§  a fourth.  It  was  not 
until  since  the  description  given  of  his  case  by  the  celebrated  English 
surgeon,  that  practitioners  have  been  willing  to  admit  of  such  a spe- 
cies of  hernia,  a species  that  forms  the  subject  of  M.  Deneux’s  ex- 
cellent monograph. 

There  are  six  sorts  of  hernia  of  the  ovary.  1.  The  inguinal, 
noticed  by  Soranus,  Verdier,  Haller,  Pott,  Lassus,  Babin,  Dessault, 
Lallement,  Rougemont,  Bessiere,  and  Billard.  2.  The  crural,  ascer- 
tained by  Messrs.  Murat  and  Deneux.  3.  Ischiatic,  by  Camper  and 
Papen.  4.  Umbilical,  by  Camper.  5.  Ventral,  by  Ruysch,  Stein  and 
Lauverjat ; 6th  and  last,  the  vaginal  or  vagino-rectal,  by  Sir  Everard 
Home,  Roux,  Barret,  Dug&s,  Madame  Boivin,  and  other  authors. 

* Oribasius.  cap.  xxxi.  and  xxxii.  lib.  xxiv. 

f Mem.  de  l’Acad.  de  Chir.,  t.  ii. 

$ Herniar.  Adnotat.  crit.  in  opusc.  pathoJ. 

§ Med.  Obs.  and  Inq.:  Works,  vol.  iii. 


Fig.  20. 


HERNIA  OF  THE  OVARY. 


199 


Cases  of  ovarian  hernia  are  met  with  on  one  side  alone,  or  on  both 
sides  at  the  same  time.  Verdier,  Lassus,  Deneux,  and  Billard  have 
proved  that  though  they  are  most  frequently  the  result  of  accident, 
they  may  also  be  congenite ; in  some  cases  the  ovary  alone  is  the 
subject  of  protrusion ; but  for  the  most  part,  that  organ  is  accompa- 
nied in  its  escape  by  the  womb,  by  portions  of  intestinal  convolutions, 
and  almost  invariably  by  the  Fallopian  tube. 

Th q predisposing  causes  of  ovaric  hernia  are  ascitic  dropsy;  sudden 
emaciation;  immoderate  use  of  relaxing  drinks,  and  fat  and  oily  food  ; 
living  in  damp  climates ; the  presence  of  Nuch’s  canal,  and  various 
displacements  of  the  womb  : during  infancy,  the  smallness  of  the 
lower  basin  of  the  pelvis,  the  straight  elongated  form  and  smooth 
surface  of  the  ovaries,  and,  lastly,  their  situation  in  front  of  the  psoas 
muscles,  and  nearly  opposite  to  the  lower  opening  of  the  abdominal 
parietes. 

The  occasional  causes  of  ovaric  hernia  are,  in  general,  those  of 
the  other  sorts  of  hernial  protrusion;  but  in  adults,  they  chiefly  consist 
in  circular  compression  acting  just  above  the  hips,  either  by  means  of  a 
belt,  or  by  a badly  constructed  corset ; the  development  of  the  womb 
and  of  the  ovary  when  diseased ; wounds  and  abscesses  of  the  hypo- 
gastric and  inguinal  regions ; in  young  patients,  loud  crying  continued 
lor  a long  time  ; the  careless  application  of  bandages  for  the  sup- 
port of  the  navel  during  the  month  ; and,  finally,  all  kinds  of  exer- 
tion capable  of  bringing  on  the  other  kinds  of  hernia  of  the  pelvic 
viscera. 

There  is  sometimes  a degree  of  obscurity  in  the  diagnosis  of  ova- 
rian hernia,  and  the  signs  of  its  existence  may  be  varied  by  inflam- 
mation, adhesion,  tumefaction,  scirrhus,  and  dropsy  of  the  organ  ; or 
by  its  containing  hydatids ; or  as  exhibiting  any  other  diseased  con- 
dition capable  of  altering  the  form  of  the  tumour,  as  well  as  the 
configuration  and  structure  of  the  ovary  itself.  In  spite  of  all  these 
modifications,  brought  about  in  the  characteristic  signs  of  ovaric  her- 
nia, it  is  possible,  with  a little  attention,  to  discriminate  between  it 
and  the  glandular  or  lymphatic  tumours,  the  cutaneous  abscesses, 
the  epiplocele,  the  enterocele,  and  the  fatty  hernia,  with  which  it 
has  been  confounded.  Where  the  displaced  ovary  preserves  its  con- 
sistence, its  mobility  and  its  natural  structure,  especially  when  it 
comes  through  the  inguinal  ring,  which  is  most  commonly  the  case, 
the  tumour,  ordinarily  about  the  size  and  shape  of  a pigeon’s  egg, 
is  circumscribed,  elastic,  painful  upon  pressure — of  a glandular  feel, 
inducing  no  change  in  the  colour  of  the  skin,  causing  no  colic  pain, 
vomiting,  or  borborygmi,  no  dragging  of  the  stomach,  no  constipa- 
tion; it  is  not  spontaneously  reduced,  and  when  the  artificial  reduction 
is  accomplished,  is  unattended  with  gurgitation  of  air,  as  in  intes- 
tinal hernia;  and  lastly,  far  from  obtaining  relief  from  lying  upon  the 
side  opposite  to  the  tumour,  the  woman,  just  as  happens  from  being 
afoot,  has  severer  pains  in  the  hypogastrium  and  loins,  and  a much 
more  distressing  sense  of  dragging.  Such  are  the  characteristic  signs 
by  which  we  may  recognize  the  hernias  of  the  ovary,  when  the 
protrusion  takes  place  outside  of  the  pelvis,  and  discriminate  be- 


200 


HERNIA  OF  THE  OVARY. 


tween  them  and  the  cases  of  entero-epiplocele,  with  which  they 
might  readily  be  confounded.  Lassus  has  judiciously  remarked  that 
there  is  no  sign  more  available  than  that  derived  from  the  connec- 
tion of  motions  communicated  to  the  womb  by  the  hand,  through 
the  vagina,  or  the  rectum,  with  thdse  felt  at  the  same  time  in  the 
tumour,  whether  by  the  hand  of  the  patient  or  that  of  the  medical 
attendant. 

In  young  women  of  a strong  habit  of  body,  an  ovarian  hernia  is 
subject  to  become  strangulated,  particularly  if  the  protrusion  happen 
to  occur  at  the  inguinal  or  femoral  opening.  The  occurrence  is  sig- 
nified by  an  increase  of  the  phenomena  above  pointed  out,  and,  some- 
times, when  the  inflammation  is  of  a high  grade,  by  the  formation  of 
an  abscess,  and  even  by  the  supervention  of  an  attack  of  peritonitis. 

It  is,  therefore,  a matter  of  the  utmost  exigency  to  reduce  an  ova- 
rian hernia  as  soon  as  practicable,  and  to  keep  it  reduced.  The  least 
delay  may  render  the  reduction  not  only  more  difficult,  but  even  out 
of  the  question.  The  ovary,  which  has  now  become  compressed, 
inflames,  swells,  and  contracts  adhesive  union,  rendering  it  impos- 
sible to  replace  it  in  its  natural  position.  It  has,  in  such  case,  been 
found  to  become  scirrhous,  which  contra-indicates  any  attempt  at 
reduction,  and  establishes  a necessity  for  the  excision  of  the  organ. 

When  an  ovarian  hernia  becomes  strangulated,  the  consequences 
resulting  from  it  are  to  be  combated  by  position,  by  general  and  local 
blood-letting,  by  baths,  fomentations,  emollient  poultices,  and  injec- 
tions ; and,  finally,  by  cutting  up  the  stricture,  should  all  other  means 
fail.  Having  carefully  uncovered  the  ovary  by  strokes  of  the  bis- 
toury, layer  by  layer,  and  relieved  the  ring  with  a probe-pointed 
bistoury,  or  by  a sound  with  the  concealed  blade,  which  is  particu- 
larly convenient  for  the  multiple  incisions,  the  contents  of  the  her- 
nial sac  should  be  returned  into  the  abdomen  should  they  prove  to 
be  sound,  and  should  the  adhesions  they  may  have  formed  admit  of 
being  broken  up.  Under  opposite  circumstances,  after  relieving  the 
stricture,  we  should  rest  contented  with  applying  mild  dressings  until 
all  inflammatory  symptoms  are  gone,  and  afterwards  make  use  of 
moderate  pressure  upon  the  part  by  means  of  a proper  bandage. 
This  method  is  always  to  be  preferred  to  the  excision ; and  the  ovary, 
after  being  carried  back  into  the  abdomen,  or,  at  least,  within  the 
ring,  will,  by  stopping  the  canal,  be  a preventive  of  enterocele  or 
epiplocele,  which  are  far  more  dangerous.  Should  dangerous  symp- 
toms or  great  inconvenience  result  from  this  procedure,  we  still  have 
within  our  reach  the  extreme  measure  of  extirpating  the  ovary, 
which  in  Potts’  case  presented  neither  difficulty  nor  danger,  he  hav- 
ing exscinded  the  ovaries  after  tying  each  of  the  ovarian  ligaments. 
The  patient  in  Mr.  Potts’  case,  as  well  as  in  M.  Lassus’  case,  (Pathol. 
Chirui'g.,)  sustained  from  this  sort  of  female  castration,  nothing  be- 
yond the  loss  of  certain  of  the  sexual  attributes  and  an  absolute  bar- 
renness. In  case  of  a scirrhous  ovary,  or  of  one  affected  with  hyda- 
tids, it  would  be  reasonable  to  perform  the  exscinding  operation  ; in 
which  event,  as  well  as  in  the  operation  for  cutting  up  the  stricture, 
the  wound  ought  to  be  dressed  in  the  same  way  as  any  simple 
wound. 


VAGINAL  CYSTOCELE. 


201 


VAGINAL  CYSTOCELE,  OR  HERNIA  OF  THE  BLADDER  IN  THE 

VAGINA. 

The  bladder,  like  most  of  the  organs  within  the  pelvis,  is  liable  to 
be  displaced,  and  to  form  various  sorts  of  hernias,  which  have  received 
the  appellation  of  Cystocele , whether  inguinal , crural , perineal , 
vaginal ’,  or  vulvar , as  they  happen  to  take  place  at  the  inguinal  ring, 
the  crural  arch,  at  the  perineum,  the  interior  of  the  vagina,  or  the 
middle  of  one  of  the  labia  externa.  As  these  two  last  modes  of  dis- 
placement are  the  only  ones  peculiar  to  the  sex,  we  shall  consider 
ourselves  as  exempt  from  the  necessity  of  describing  the  other  three 
kinds. 

To  judge  from  the  principal  treatises  upon  general  surgical  patho- 
logy, and  even  from  the  most  approved  monographs  on  hernia,  and 
from  all  the  ancient  and  modern  works  specially  devoted  to  the  dis- 
eases of  women,  the  hernia  of  the  bladder  called  vaginal  cystocele, 
ought  to  be  looked  upon  as  the  worst  of  all  displacements.  The 
illustrious  Scarpa,  in  his  admirable  treatise  on  hernia,  Samuel  Cooper, 
in  his  excellent  Dictionary,  Dupuytren,  in  his  Lectures,  never  spoke  of 
this  case.  Boyer,  in  the  treatise  Des  Maladies  Chirurgicales,  Messrs. 
Roche  and  Sanson  in  their  Elements  de  Pathologie  ext  erne,  and, 
in  fact,  most  of  the  highest  modern  authorities  scarcely  speak  on  this 
point,  so  that  we  have  but  a few  facts  observed  by  Mery,*  Curade 
of  Avignon,  Robert,  of  Lille, t Divoux,f  Christian,  of  Liverpool, § 
Sandifort,||  Chaussier,1F  Sims,**  Astley  Cooper, ft  Rognetta,lt  and 
Madame  Rondet,§§  a midwife  at  Paris. 

To  one  perfectly  acquainted  with  the  connection  of  the  vagina 
and  bladder,  it  is  easy  to  understand  the  mechanism  of  a vaginal 
cystocele ; the  urinary  sac  being  pushed  against  the  anterior  wall  of 
the  vagina  by  a sudden  descent  of  the  diaphragm  and  violent  con- 
tractions of  the  abdominal  muscles,  to  a certain  degree  depresses  that 
wall,  or,  passing  through  a split  in  the  vaginal  fibres,  gives  rise  to  a 
membranous  fluctuating  tumour,  that  projects  within  the  vagina,  or 
even  appears  external  to  the  labia  majora. 

The  predisponent  causes  of  vaginal  cystocele  are:  too  large  a 
pelvis ; numerous  repetitions  of  pregnancy  and  labour ; a lymphatic 
temperament;  an  erect  position  too  long  and  too  frequently  continued; 
an  occupation  compelling  the  patient  to  bear  heavy  burdens,  or  to 

* Mem.  de  l’Acad.  des  Sci.  ann.  1713.  Yerdier,  Recherches  sur  la  Hernie  de  la 
Vesie.  Boyer,  t.  viii.  p.  372. 

f Mem.  de  l’Acad.  de  Chir.,  t.  ii.  Yerdier,  [loc.  cit.] 

t Disp.  de  Hernia  Vesica  Urinaria,  1732. 

§ The  Edin.  Med.  Journ.,  ix.  281. 

||  Observat.  Anatomica.,  t.  i.  cap.  3.  p.  58. 

t Leblanc  Precis,  des  Operations  de  Chir.,  ii.  368. 

**  Sir  Astley  Cooper  on  Abdominal  Hernia,  p.  57. 

ff  On  Abdominal  Hernia,  loc.  cit. 

it  Considerations  sur  la  Cystocele  Vaginale,  &c.,  (Rev.  Medicale,  June,  1832,  p, 
398.)  This  memoir  of  Dr.  Rognetta  is,  beyond  contradiction,  the  best  monograph  on 
the  subject  of  Vaginal  Cystocele.  By  his  experiments  upon  the  dead  subject,  he  has 
thrown  much  light  upon  the  mechanism,  symptoms,  progress,  diagnosis  and  treat- 
ment of  various  displacements  of  the  urinary  bladder  in  the  female. 

§§  Mem.  sur  la  Cystocele  Vaginale,  1835. 


202 


VAGINAL  CTSTOCELE. 


make  too  violent  exertion  of  the  muscular  power ; a chronic  leucor- 
rhoea ; pregnancy ; retention  of  urine,  and  the  habit  of  discharging 
it  too  seldom;  abusus  coitus;  hot  hip-baths;  foot-warmers;  tight 
lacing,  especially  with  a steel  or  whalebone  busk ; and,  lastly,  a 
peculiar  laxity  of  the  texture  of  both  the  vagina  and  bladder,  and  a 
certain  conformation  by  which  the  bladder  is  enlarged  at  the  sides, 
and  sunk  down  behind  the  symphysis  pubis. 

In  general,  vaginal  cystocele  is  not  to  be  met  with  except  in  women 
who  have  had  children  ; yet  a case  fell  under  the  notice  of  Sandifort, 
in  a young  hysterical  girl,  who  had  been  tormented  by  a spasmodic 
cough,  ( Obs . Jbiat.,  t.  i.  p.  58,)  and  one  under  that  of  Sir  Astley 
Cooper,  in  a girl  of  seventeen,  admitted  at  Guy’s  Hospital  for  a sup- 
posed falling  of  the  womb.*  The  disorder  has  been  noticed  in  the 
pregnant  female  by  Mery  and  Curade  of  Avignon,  (loc.  cit.,)  during 
labour,  by  Robert,  at  Lille,  and  by  Christian,  at  Liverpool,  (loc.  cit.;) 
and  lastly,  as  late  as  seven  days  after  childbirth,  by  Chaussier,  (Le- 
blanc, Precis,  des  Operat.  tie  Chir .,  t.  ii.  p.  36S.)  In  this  case,  the 
vesical  hernia  came  on  in  consequence  of  a violent  effort  that  the 
patient  made  in  moving  a bucket  of  water. 

Among  the  determining  causes  of  cystocele,  ought  to  be  classed 
the  labour  of  parturition,  violent  exertions,  strong  pressure  on  the 
hypogaster.  jumping,  dancing,  coughing,  vomiting,  trotting  on  horse- 
back, the  jolting  of  a carriage  without  springs,  and,  in  fact,  most  of 
the  efficient  causes  of  other  kinds  of  hernia. 

It  shows  itself  by  a tumour  formed  by  the  bladder  depressing  the 
anterior  walls  of  the  vagina,  and  presenting  itself  either  within  the 
canal  or  outside  of  the  orifice  of  the  vulva.  The  tumour  is  reddish, 
[bluish — M.,J  rounded,  tense,  and  with  a polished  surface,  when  the 
bladder  is  full  enough  to  have  distended  the  rugee  of  the  mucous 
surface  of  the  vagina.  On  the  contrary,  it  is  uneven,  wrinkled,  and 
soft,  when  the  bladder  contains  little  or  no  fluid.  In  the  former  case, 
it  fluctuates,  and,  when  pressed  from  below  upwards,  it  disappears; 
but  the  urine  escapes  from  the  meatus  urinarius,  and  smells  so  much 
the  more  offensively,  as  it  has  been  longer  detained  within  the 
bladder.  In  fine,  violent  exercise,  long  walks,  and  long  standing 
increase  the  size  of  the  tumour,  which,  on  the  contrary,  diminishes 
under  rest  and  the  horizontal  posture. 

Vaginal  cystocele  always  produces  dysury,  and  sometimes  ischu- 
ria; it  also  causes  a stinging  sensation  in  the  urethra,  and,  in  some 
instances,  a very  painful  tension  and  increased  size  of  the  abdomen ; 
symptoms  that  are  mostly  attended  with  agitation — Sleeplessness, 
dragging  of  the  stomach,  and  a variety  of  sympathetic  phenomena. 

This  species  of  displacement  of  the  bladder  exhibits  itself  either 
separately  or  complicated  with  cystitis,  metritis,  and  not  unfrequently 
with  vaginitis,  or  various  uterine  deviations,  as  anteversion,  retro- 
version, or  a more  or  less  complete  prolapsion.  All  such  complica- 
tions of  vaginal  cystocele  should  be  met  by  an  antiphlogistic  treat- 

* [Dr.  Matter  recently  met  with  a case  in  a child  six  months  old.  The  whole 
bladder,  filled  with  urine,  was  protruded  beyond  the  genital  fissure  during  a con- 
vulsion.— M.J 


VAGINAL  CYSTOCELE. 


203 


ment,  employed  coincidently  with  the  management  of  the  primary 
disorder. 

When  this  vesical  hernia  occurs  in  a pregnant  woman,  it  may 
become  so  large  as  to  obstruct  the  passage  of  the  fetus.  It  would 
always  be  easy  here  to  discriminate  between  the  urinary  bladder 
and  the  bag  of  amniotic  waters  by  introducing  the  index  into  the 
vagina,  so  as  to  make  sure  that  the  os  tincse  is  free  and  situated 
behind  the  cystic  tumour,  which  may  readily  be  made  to  disappear 
by  drawing  off  its  contents  with  the  catheter.  This  proceeding  was 
successful  in  the  hands  of  both  Baudelocque  and  Robert,  of  Lille. 

A vaginal  cystocele,  developed  within  a few  days  after  a woman’s 
confinement,  may  become  sufficiently  large  to  interfere  with  the  es- 
cape of  the  lochia  until  the  swelling  is  reduced.  This  actually  hap- 
pened in  Chaussier’s  case,  related  by  Hoin  and  Leblanc  (loc.  cit.) 

It  has  also  been  found  that  the  projecting  part  of  the  bladder, 
within  the  vagina,  contained  urinary  calculi  that  were  removed  by 
incising  the  tumour  itself.  Francois  Tolet*  removed  five  in  this 
way,  and  Ruyscht  in  the  same  manner  extracted  forty-two  of  them. 

The  treatment  of  vaginal  cystocele  presents  two  chief  indications, 
which  are,  as  for  all  other  cases  of  hernia,  to  reduce  the  tumour,  and 
prevent  its  future  displacement.  Where  the  cystocele  is  a small  one, 
it  may  be  easily  restrained,  either  by  means  of  a sponge  cut  into  a 
cylindrical  shape  and  impregnated  with  some  astringent  liquid, % or 
by  a gum-elastic  pessary,  en  bondon  ; or  by  Rognetta’s  pessary ; or 
simply  by  means  of  a sachet  of  fine  linen,  filled  with  oak  bark  soaked 
in  red  wine,  and  kept  in  situ  by  means  of  a T bandage. 

When  the  vesical  hernia  is  a large  one,  and  is  compressed  by  the 
womb  and  the  adjacent  parts,  the  treatment  should  be  commenced 
with,  what  is  always  useful  in  such  cases,  the  introduction  of  the 
catheter — a male  catheter — taking  care  to  turn  the  concave  part  of 
the  instrument  towards  the  vagina,  so  as  to  correct  the  faulty  position 
of  the  urethra,  which  is  ordinarily  met  with  in  the  case.  If,  notwith- 
standing all  attempts,  it  should  be  found  impossible  to  use  the  cathe- 
ter, and  particularly  if  the  patient  be  in  labour,  and  incapable  of 
delivery  on  account  of  the  obstruction,  a trocar  ought  to  be  plunged 
into  the  centre  of  the  tumour ; and  when  the  urine  is  discharged,  a 
catheter  should  be  left  in  the  bladder,  to  prevent  the  formation  of  a 
vesico-vaginal  fistula. 

In  case  the  catheter  were  passed  into  the  bladder,  without  inducing 
a flow  of  the  urine,  let  the  tumour  be  compressed,  as  in  Robert’s 
case,  so  as  to  compel  the  liquid  to  flow  towards  the  open  end  of  the 
instrument. 

The  interesting  observations  made  by  Mr.  Burns,  of  Glasgow,  in 
the  dissection  of  a case  of  vaginal  cystocele, § would  go  to  show  that 

* Traite  de  la  Lithotomie  ou  de  l’Extraction  de  Ja  Pierre  de  la  Vessie. 

f Adversaria  Anat.  Chir.  Med.,  (Joe.  cit.) 

f Dr.  d’Huc,  in  his  Manual  le  Mededn  des  Femmes , p.  61,  recommends  the  following 
decoction,  which  seems  to  us  to  he  very  suitable:  B.  Khatany,  bruised,  Jss.;  water, 
lbj. ; boil  the  mixture,  and  at  the  close  of  the  boiling,  add  Provence  roses,  3i;  strain 
the  liquor.  * 

§ Mr.  Burns’  anatomical  observations  are  in  the  Transactions  of  the  Edin.  Med. 


204  PROLAPSION  OF  THE  URETHRAL  MUCOUS  MEMBRANE. 

this,  like  other  forms  of  hernia,  is  liable  to  strangulation.  The  cele- 
brated English  anatomist,  as  a means  of  relieving  it,  proposes  to 
apply  the  bistoury  to  the  part  strangulated.  This  seems  to  us  to  be 
both  dangerous  and  useless ; for  even  should  a strangulation  take  place, 
— and  no  such  instance  has  been  met.  with, — it  might  be  overcome 
either  by  drawing  off  the  urine  with  the  catheter,  or,  as  we  have 
above  advised,  by  plunging  a trocar  into  the  bladder  through  the 
vaginal  paries,  if  the  application  of  the  catheter  is,  or  should  be  found 
to  be  wholly  impracticable. 

We  cannot  close  this  chapter  without  remarking  that  there  is  a 
species  of  cystocele  that  might  be  called  urethral,  from  the  fact  that 
the  bladder  turns  out  through  the  canal  of  the  urethra,  and  presents 
itself  at  the  meatus  urinarius,  which  it  completely  fills  up  and  ob- 
structs. This  form  of  cystocele,  very  rare  it  is  true,  was  met  with 
by  Dehaen,*  and  is  always  coincident  with  an  intestinal  hernia, 
pressing  the  vagina  downwards  and  carrying  along  with  it  the  blad- 
der of  urine. 

A perineal  cystocele  in  the  female,  requires  the  same  treatment  as 
the  vaginal  cystocele,  and  exhibits  nearly  the  same  diagnostic  signs. 
The  perineum  is  occupied  with  a large,  indolent,  slightly  elevated 
swelling,  that  is  soft,  disappearing  readily  on  pressure,  or  upon  the 
evacuation  of  the  bladder ; and  increasing  in  size  and  firmness  when 
the  bladder  is  full  of  urine. 

PROLAPSION  OF  THE  MUCOUS  MEMBRANE  OF  THE  URETHRA. 

Prolapsus  of  the  internal  membrane  of  the  urethra  is  a very  rare 
disorder,  on  which  it  is  necessary,  nevertheless,  to  offer  a few  remarks. 
This  affection,  which  is  owing  to  a relaxed  and  thickened  state  of  the 
mucous  coat,  is  known  by  a small  reddish  tumour  projecting  more 
or  less  considerably  from  the  orifice  of  the  urinary  meatus,  and  dis- 
tinguishable from  the  urethral  fungus,  of  which  we  are  hereafter  to 
speak,  by  its  regular  shape,  its  reducibility,  and  especially  by  the 
opening  discoverable  in  its  centre.  In  a case  of  this  kind,  noticed  by 
Seguin,t  the  finger  could  be  introduced  into  the  urethra,  which  was 
extremely  dilatable  and  relaxed;  after  having  vainly  made  use  of 
astringents,  he  passed  a female  catheter  into  the  urethra,  and  applied 
a ligature  upon  the  instrument  and  protruded  membrane,  which  was 
followed  by  her  complete  recovery  in  the  course  of  eight  days.  We 
have  been  equally  successful,  by  cauterizing  the  whole  length  of 
the  canal  with  a concentrated  solution  of  nitr.  of  silver,  which  was 
applied  upon  a bit  of  sponge  fixed  in  a small  cylinder  with  one  of 
the  sides  open.  The  patient  in  question,  who  is  now  twenty  years 
of  age,  although  stout  and  well  made,  has  the  organs  of  generation 
in  an  evidently  relaxed  state  ; the  womb  is  generally  an  inch  from 
the  vulva  ; both  the  labia  majora  and  minora  are  drooping,  soft,  and 

Soc.,  ann.  1824,  and  in  Sir  Astley  Cooper’s  Anatomy  and  Surgical  Treatment  of  Ab- 
dominal Hernia,  64. 

* Ratio  Medendi,  t.  i.  p.  76.  t Biblioth.  Med.,  t.  lxviii.  p.  86. 


VAGINAL  ENTEROCELE. 


205 


much  more  elongated  than  usual.  She  was  married  at  sixteen,  and 
has  twice  been  delivered  of  dead  children  in  consequence  of  falling 
on  the  stairs.  She  is  a washerwoman,  which  requires  her  to  be  con- 
stantly on  foot,  which,  with  her  exertions  in  frequently  carrying 
clothes  to  a great  distance,  may,  conjointly  with  a peculiar  idiosyn- 
crasy, be  looked  on  as  the  predisposing  causes  of  the  relaxed  and 
unnatural  state  of  all  her  genital  organs. 

VAGINAL  ENTEROCELE. 

Vaginal  enterocele  consists  in  a tumour  that  projects  into  the  va- 
gina, and  that  is  produced  by  the  displacement  of  a portion  of  a 
bowel.  This  kind  of  hernia,  rather  less  rare  than  the  other  kinds,  is 
well  understood  at  the  present  day.  Garengeot*  is  the  first  author 
who  mentions  it;  since  whom  it  has  been  observed  by  Verdier,t 
Leblanc4  Hoin,§  Richter, ||  Dehaen,f  and  several  other  practitioners. 

The  portions  of  the  vagina  that  are  lined  by  the  peritoneum,  that 
is  to  say,  the  anterior  and  posterior  walls,  are  the  only  ones  that  can 
give  way  before  an  intestinal  protrusion  into  the  cavity  of  the  tube. 
The  predisposing  causes  of  this  sort  of  displacement  are  partly  the 
same  as  those  of  other  hernias — thus,  pregnant  women,  women 
newly  delivered,  and  such  as  have  many  children,  are  more  liable  to 
it  than  others.  Out  of  fifteen  cases  of  vaginal  enterocele,  made  public 
by  Hoin,#thirteen  were  in  persons  who  had  been  confined  a few  days 
beforehand ; however,  the  affection  has  been  noticed  in  women  who 
had  never  been  confined. 

The  occasional  causes  of  this  hernia,  which,  however,  may  be 
formed  in  a slow  and  gradual  manner,  are,  in  general,  a fall  upon 
the  buttock,  an  effort  to  raise  a heavy  burthen,  at  stool,  and,  indeed, 
almost  all  the  occasional  causes  of  the  other  modes  of  displacement. 
Where  a vaginal  enterocele  has  been  suddenly  produced,  the  patient 
feels  as  if  something  was  descending  along  the  course  of  the  vagina, 
and  a pain,  greater  or  lesser,  that  spreads  throughout  the  entire  ab- 
domen.. The  tumour  from  this  hernia,  which  is  commonly  not  trou- 
blesome, unless  it  becomes  very  large,  is  of  a soft  consistence,  and  is 
partially  effaced  or  wholly  disappears  when  the  patient  lies  down. 
On  the  contrary,  it  becomes  larger,  harder,  more  tense,  and  presents  a 
larger  base,  is  of  a round  or  oval  shape,  and  in  some  instances  appears 
to  jut  at  the  vulva,  while  the  patient  stands  up  or  makes  any  muscular 
effort.  In  a word,  the  vaginal  enterocele  exhibits  all  the  general 
characters  of  the  other  kinds  of  hernia.  By  carrying  the  index  to 
the  os  tincse,  it  is  found  free  and  in  its  natural  position.  This  circum- 
stance, added  to  the  absence  of  any  opening  in  the  tumour,  and  the 
other  signs  enumerated,  prevent  us  from  confounding  a vaginal  en- 
terocele with  any  other  tumour  developed  in  the  vagina. 

* Mem.  de  l’Acad.  de  Chir.,  t.  ii. 

f Recherches  sur  la  Hernie.  Mem.  de  l’Acad.  de  Chir.,  t.  ii. 

* Nouvel  Methode  d’Oper.  les  hernies,  1767. 

§ Essai  sur  les  Hernies  rares  et  peu  connues,  1767. 

H Von  der  Broken,  &c.,  translated  by  Rougemont,  1799. 

1 Ratio  Medendi,  t.  i.  loc.  citat. 


206 


VAGINAL  ENTEROCELE. 


When  the  displaced  portion  of  bowel  penetrates  betwixt  the  blad- 
der and  the  womb,  the  hernia  appears  at  one  of  the  sides  of  the 
anterior  surface  of  the  vagina  near  the  os  uteri;  but  it  is  upon  the 
posterior  surface  of  the  canal,  when  the  gut  has  fallen  down  between 
the  rectum  and  the  womb.  In  the  latter  case,  the  tumour  is  often 
found  to  extend  down  to  the  vulva,  or  even  outside  of  it,  pressing 
the  perineum  outwards  and  compressing  the  extremity  of  the  rec- 
tum, so  as  to  render  the  expulsion  of  the  faeces  very  painful. 

The  thinness  and  weakness  of  the  walls  of  the  vagina,  the  great 
size  of  the  pedicle  of  the  tumour,  that  is  to  say,  of  the  communi- 
cation of  the  hernial  sac  with  the  abdomen,  always  admit  of  the 
return  of  the  intestine  and  omentum,  and,  to  a certain  degree,  render 
it  impossible  that  vaginal  enterocele  should  be  liable  to  strangula- 
tion. Nevertheless,  from  the  cases  of  Smellie  and  Dehaen,  it  seems 
that  the  pressure  of  the  gravid  uterus  may  cause  such  an  accident  to 
happen,  which  it  is  difficult  to  overcome  in  a case  where  the  tumour 
is  of  considerable  size. 

As  a remedy  for  this  kind  of  strangulation,  in  case  the  reduction 
should  be  found  impossible,  of  which  no  example  has  been  hitherto 
found,  it  has  been  recommended  to  cut  down,  upon  the  most  salient 
point  of  the  tumour,  and  then  dilate  the  opening  by  which  the  bowel 
ought  to  be  returned,  with  Leblanc’s  instrument  for  facilitating  the 
reduction  of  displaced  parts.  Some  surgeons  have  supposed  that  an 
incision  ought  to  be  made  into  the  abdomen,  so  as  to  permit?  the  parts 
to  be  disengaged  by  coming  at  them  through  such  opening : and, 
lastly,  where  a vaginal  enterocele  is  found  to  be  omental  and  pedicel- 
lated,  it  has  been  recommended  to  tie  up  the  root  with  a ligature ; 
but  it  is  very  difficult  to  determine,  h priori , which  of  these  three 
surgical  measures  is  best  adapted  to  ensure  success.  To  decide  this 
question,  we  must  necessarily  wait  until  experience  and  the  candid 
observation  of  cases  shall  suffice  to  remove  all  uncertainty  on  the 
subject. 

Under  these  difficult  circumstances,  the  possibility  of  which,  though 
never  yet  met  with,  is  admitted,  the  conduct  to  be  pursued  i£  uncer- 
tain ; but  such  is  not  the  fact  with  regard  to  the  great  majority  of  the 
cases.  Indeed,  the  treatment  of  vaginal  enterocele  is  very  simple 
and  well  understood,  consisting,  as  in  all  other  hernias,  in  reducing 
and  in  keeping  the  tumour  reduced. 

For  the  reduction,  we  begin  by  evacuating  the  rectum  with  injec- 
tions; and  then,  placing  the  patient  on  her  back,  with  the  head  and 
trunk  lower  than  the  pelvis,  and  the  thighs  flexed,  we  introduce  two 
of  the  right  hand  Angers,  well  anointed,  into  the  vagina.  The  posi- 
tion of  the  pelvis  should  be  changed  so  as  to  make  the  womb  press 
as  little  as  possible  upon  the  tumour,  which  should  now  be  gently 
compressed  so  as  to  cause  it  to  return,  little  by  little,  until  the  whole 
has  passed  back  into  the  abdomen.  Should  the  tumour  have  passed 
out  through  the  posterior-superior  part  of  the  vagina,  the  patient, 
instead  of  lying  upon  the  back,  ought  to  be  on  her  knees  upon  the 
mattress,  with  the  head  lying  upon  it.  When  the  hernia  is  reduced, 


VAGINAL  ENTEROCELE. 


207 


it  .should  be  kept  so  by  a cylindrical  pessary,  maintained  in  situ  with 
a T bandage. 

Previously  to  closing  these  remarks,  let  us  add  that  emollient  fumi- 
gations, directed  into  the  vagina,  and  also  oily  injections  into  the 
part,  before  proceeding  to  the  above  manoeuvres,  will  greatly  facili- 
tate the  reduction  of  a vaginal  enterocele. 

[I  recently  attended  a woman  in  labour  with  vaginal  enterocele,  an 
account  of  which  was  published  in  Professor  Huston’s  Med . Examiner , of 
Oct.  5,  1844,  and  which  I transfer  to  these  pages,  as  a case  interesting  from 
its  rarity. 

Mrs.  R.,  aged  about  thirty  years,  the  mother  of  four  children,  all  of  whom 
were  born  by  easy,  natural  labours,  and  one  of  them  in  a labour  of  two 
hours,  was  seized  with  the  parturient  pains  at  half  past  eleven  o’clock  last 
night.  She  was  at  full  term,  and  in  good  health,  save  that  she  had  com- 
plained much  of  an  unusual  pain  in  the  right  side  of  the  abdomen,  and  par- 
ticularly in  the  right  iliac  region. 

Her  physician,  Dr.  Bicknell,  was  called  to  the  charge  of  the  case.  Dr. 
B.  discovered  a tumour  occupying  the  cavity  of  the  pelvis,  which  impeded 
the  progress  of  the  labour.  The  woman’s  pains  were  frequent  and  violent, 
and  attended  with  the  most  excessive  tenesmic  effort  at  bearing  down.  Dr. 
B.  invited  me  to  see  the  patient;  and  I arrived  at  2 o’clock,  P.  M.,  at  her 
house  in  West  Philadelphia. 

The  external  parts  were  in  a relaxed  state.  The  index  finger  used  in 
touching,  was  pressed  towards  the  symphysis  pubis  by  the  tumour,  which 
seemed  nearly  to  fill  up  the  pelvic  cavity  and  effectually  to  debar  the  head 
even  from  engaging  in  the  superior  strait,  though  the  labour  had  continued 
already  fourteen  and  a half  hours,  in  the  case  of  a woman  who,  in  other 
labours,  was  occupied  but  two  hours  with  the  whole  process. 

I could  just  conveniently  touch  the  presenting  part  of  the  head,  which 
was  in  the  fourth  position  of  the  vertex  presentation.  The  os  uteri  fully 
dilated. 

The  tumour  was  compressible.  I touched  by  the  rectum,  and  so  disco- 
vered that  the  tumour  was  in  the  peritoneal  cul-de-sac,  betwixt  the  rectum 
and  vagina,  but  distending  that  cul-de-sac  enormously.  The  diagnosis  could 
be  nothing  else,  considering  the  softness  of  the  swelling,  than  a vaginal  ente- 
rocele, which  I immediately  proceeded  to  reduce. 

The  woman  was  placed  on  her  left  side ; the  knees  drawn  up.  I intro- 
duced all  the  fingers  of  the  right  hand  into  the  passage,  and  pressed  the  ends 
of  them  against  the  lower  part  of  the  tumour.  By  keeping  up  the  pressure 
a short  time,  during  which  I repeatedly  exhorted  the  woman  to  be  passive, 
and  not  to  bear  down  at  all,  I could  cause  the  whole  mass  of  the  swelling 
to  rise  up  towards  the  back  part  of  the  superior  strait.  As  the  mass  as- 
cended, it  grew  smaller,  until,  on  a sudden,  the  whole  tumour  slipped  beyond 
the  reach  of  the  hand,  and  was  lost.  I announced  this  good  fortune  to  the 


20S 


VULVAR  ENTEROCELE  AND  CTSTOCELE. 


patient,  and  exhorted  her  not  to  bear  down  at  all  with  the  approaching  pain, 
lest  the  gut  should  again  prolapse.  The  pain  that  ensued  brought  the  head 
nearly  through  the  superior  strait,  and  partially  rotated  the  vertex.  The 
second  pain  rotated  the  head,  and  propelled  it  on  to  the  perineum ; the  third 
brought  the  vertex  considerably  beyond  the  pubic  arch,  and  the  fourth 
expelled  a very  large  and  healthy  child;  after  which  the  placenta  came  off 
in  a few  minutes. 

I look  upon  this  as  a very  interesting  case,  not  merely  on  account  of  the 
rareness  of  vaginal  enterocele  in  the  pregnant  female,  but  as  exhibiting  the 
power  of  such  a tumour  to  suspend  and  impede  the  progress  of  a labour  in 
all  other  regards  natural  and  healthy. 

I presume,  as  so  many  hours  had  already  elapsed  in  vain  and  exhausting 
efforts  bv  a strong  woman,  that  there  was  reason  to  fear  a dangerous  stran- 
gulation or  contusion  of  the  displaced  bowel ; and  that  it  was  fortunate  for 
the  patient  that  the  intestine  could  be  returned  above  the  plane  of  the  strait. 
The  rapidity  with  which  the  head  passed  through  the  whole  pelvis  and  the 
soft  parts,  as  soon  as  the  obstruction  was  removed,  showed  conclusively  that 
the  vaginal  enterocele  was  the  cause  of  her  distress.  As  I have  never  met 
with  such  a case  before,  I thought  that  the  publication  of  it  might  prove 
useful  to  some  of  our  readers,  should  one  of  them  happen  to  meet  hereafter 
with  a similar  instance  of  difficulty. — M.] 

VULVAR  ENTEROCELE  AND  CYSTOCELE. 

Enterocele  and  cystocele  of  the  vulva,*  are  tumours  formed  in  one 
of  the  labia,  either  by  the  descent  of  an  intestine,  or  of  the  bladder  of 
urine.  In  this  kind  of  hernia,  the  displaced  parts  descend  along  side 
of  the  vagina,  without  distending  its  walls,  and  advance  betwixt  its 
lower  extremity  and  the  ramus  of  the  ischium  into  the  middle  of  one 
of  the  labia  pudendi,  where  they  constitute  a round,  firm  tumour,  of 
greater  or  less  magnitude.  This  tumour  both  raises  up  the  skin  ex- 
ternally, and  projects  inwards  into  the  vulva,  and,  prolonging  itself  on 
either  side  of  the  vagina,  is  found  to  become  harder  and  more  tense 
when  she  coughs  or  bears  down,  while  in  a standing  position.  It  is 
often  the  seat  or  radiating  point  of  pain,  augmented  by  violent  exer- 
cise and  diverging  towards  different  parts  of  the  abdomen. 

This  kind  of  displacement  was  first  described  by  Sir  Astley  Cooper, 
who  denominated  it  a pudendal  hernia,  translated  by  the  French  into 
vulvar  hernia.  Since  the  publication  by  the  celebrated  English  sur- 
geon, Scarpa, t whose  recent  loss  is  so  universally  deplored,  met  with 
two  instances  of  it  in  his  practice.  One  was  also  noticed  by  Profes- 

* From  a case  of  vaginal  cystocele,  dissected  by  Mr.  Burns,  of  Glasgow,  it  would 
seem  that  one  side  of  the  bladder,  or  even  both  at  once,  where  they  join  the  vagina, 
may  descend  separately  along  the  canal  and  force  a passage  even  into  the  substance 
of  the  labia,  where  the  hernia  appears  as  a round  tumour,  which  partially  disappears 
upon  the  emptying  of  the  bladder.  The  middle  portion  of  the  bladder  may  also  pass 
through  the  front  of  the  vagina,  and  appear  as  a tumour  at  the  ostium  vulva), 
f Archives  Generates  de  Med.,  t.  i.  ann.  1823. 


INVERSION  OF  THE  VAGINAL  MUCOUS  MEMBRANE. 


209 


sor  J.  Cloquet,  at  the  hospital  St.  Louis ; and  another  was  seen  by 
Dug6s,*  in  a young  girl,  who  was  supposed,  by  a midwife,  to  be 
labouring  under  prolapsus  uteri. 

Examples  of  vulvar  cystocele  have  been  still  more  rarely  met  with. 
M Bompard  published  the  first  case  ; but  up  to  the  present  time  no 
one  has  discussed  and  ascertained  its  real  nature,  save  M.  Hartmann. 

The  treatment  of  the  affection  consists  in  effecting  its  reduction, 
and  in  keeping  it  reduced.  For  this  end,  the  woman  should  lie  upon 
the  back,  the  hips  and  shoulders  being  raised  by  pillows  so  as  to  relax 
the  abdominal  muscles ; and  with  the  thighs  properly  flexed  and  sepa- 
rated. Having  introduced  the  right  index  into  the  vagina,  when  the 
hernia  is  on  the  right  side,  and  the  left  one  if  it  is  on  the  opposite  side, 
the  operator  being  seated  in  front  of  the  patient  will  gently  compress 
the  tumour  along  one  side  of  the  vagina,  and  embracing,  with  the 
fingers  of  the  other  hand,  the  projecting  part  of  the  tumour  in  the 
labium,  he  will  push  it  backwards  towards  the  excavation  of  the  pel- 
vis in  a direction  parallel  with  the  vagina.  The  tumour  will  be  known 
to  be  reduced  by  the  void  that  it  leaves  in  the  labium,  and  the  cor- 
responding part  of  the  vagina. 

For  the  prevention  of  a new  displacement,  recourse  should  now 
be  had  to  the  adjustment  of  a pessary  cn  bond-on , or  what  is  still 
better,  a conoidal  pessary,  the  base  upwards,  to  be  retained  by  a T 
bandage. 

A vulvar  hernia  is,  like  other  species,  liable  to  strangulation  ; but 
both  Sir  Astley  Cooper  and  Scarpa,  who  met  with  the  accident,  suc- 
ceeded in  effecting  the  reduction  by  the  mere  taxis.  However,  as  a 
less  fortunate  instance  might  occur,  where  the  cutting  up  of  the  stric- 
ture might  be  found  indispensable,  we  are  of  opinion  that  the  following 
method  should  be  pursued  in  the  management  of  such  a case.  After 
placing  the  woman  as  before  directed,  an  incision  should  be  made 
parallel  to  the  ramus  of  the  ischium ; that  is  to  say,  the  incision  of 
the  stricturing  edge  should  be  in  a direction  backwards,  and  some- 
what obliquely  outwards — or  forwards  and  somewhat  inwards — by 
so  doing  we  should  avoid  wounding  the  vaginal  artery,  which  must 
be  within  the  sac,  and  the  pudic  which  is  situated  outside  of  it.  Let  us 
add,  that  the  chief  inconvenience  arising  from  a vulvar  hernia  consists 
in  a diminution  of  the  size  of  the  vagina,  one  of  the  sides  of  which 
projects  inwards  in  conformity  with  the  magnitude  of  the  displaced 
viscera.  This,  at  least,  is  what  was  ascertained  from  the  case  of  the 
girl  mentioned  by  M.  Duges,  and  which  we  just  now  referred  to. 

OF  INVERSION  AND  SWELLING  OF  THE  LINING  MEMBRANE  OF  THE 

VAGINA. 

Under  this  title  have  been  improperly  included  various  displace- 
ments, such  as  cystocele  and  enterocele  of  the  vagina,  the  inversion 
accompanying  prolapsus  uteri,  and  various  other  hernias  that  differ 
essentially  from  each  other,  and  possess  nothing  in  common  beyond 
the  saiiency  of  the  lining  membrane  of  the  vagina  into  its  canal,  or 

* Traite  des  Mai.  de  l’Uterus  par  Madame  Boivin  and  M.  Duges,  t.  ii.,  599. 

14 


210 


INVERSION  OF  THE  VAGINAL  MUCOUS  MEMBRANE. 


betwixt  the  labia  pudendi.  It  is  important,  therefore,  to  deter- 
mine precisely  what  is  to  be  understood  by  prolapsion,  or  fall  of  the 
vagina,  so  as  to  avoid  all  confusion  likely  to  make  the  diagnosis  more 
difficult,  and  add  to  the  obscurity  of  its  description  and  study.  By 
tall  of  the  vagina,  then,  nothing  more  is  meant  than  an  affection 
analogous  to  fall  of  the  rectum ; that  is  to  say,  an  inversion  of  the 
internal  lining  membrane,  caused  by  infiltration  of  the  cellular  tex- 
ture that  unites  the  mucous  to  the  subjacent  membranes. 

Falling  of  the  vagina  is  distinguished  into  complete  and  incom- 
plete ; in  the  former,  the  tumour  projects  more  or  less  beyond  the 
vulva,  while  in  the  latter  case,  it  merely  appears  to  be  prominent 
within  the  ostium-vaginae.  It  has  also  been  divided  into  universal 
and  partial,  accordingly  as  the  tumour  is  formed  by  the  whole  cir- 
cumference of  the  vagina,  or  simply  by  some  portion  of  the  lining 
membrane,  as  frequently  happens,  especially  as  to  that  upon  the 
anterior  surface  of  the  canal. 

The  predisposing  causes  are  a lymphatic  temperament,  a profuse 
chronic  leucorrhoea,  a frequent  repetition  of  the  act  of  parturition, 
and  of  abortion ; the  abuse  of  hot  baths,  and  of  relaxing  drinks ; an 
habitual  bad  nutrition,  and  all  the  causes  of  debility  and  cachexy. 

Among  the  efficient  causes  of  falling  of  the  vagina,  should  be 
enumerated  abiisus  coitus ; masturbation  ; the  friction  and  compres- 
sion of  the  walls  of  the  vagina  by  the  head  of  the  child  in  labour,  or  by 
the  accoucheur’s  hand  or  his  instruments  during  an  obstetric  operation. 
It  may  also  be  brought  on  by  the  causes  common  to  all  the  species  of 
hernia,  such  as  external  violence,  efforts  at  lifting  heavy  weights,  or 
in  the  expulsion  of  the  faeces ; and,  in  fine,  the  shock  of  a fall,  of  leap- 
ing, of  laughing,  sneezing,  coughing,  and  particularly  of  vomiting. 
It  has  been  produced  by  the  blow  of  a cow’s  horn,  which  struck 
upon  the  vagina.  Professor  Dcsormeaux,  who  relates  the  case,  says 
that  mostly  in  women,  about  the  change  of  life,  a partial  falling  of 
the  vagina  is  caused  by  chronic  inflammation,  whose  origin  is  to  be 
sought  in  some  herpetic  taint,  but  that  it  is  sometimes  impossible  to 
discover  the  real  cause. 

The  symptoms  of  falling  of  the  vagina  vary  in  proportion  to  the 
extent  of  the  displacement,  and  the  degree  of  the  inflammation.  In 
a partial  but  simple  prolapsus,  the  tumour  is  rounded,  or  it  is  double, 
or  it  forms  a circular  cushion,  accordingly  as  the  descent  implicates 
both  the  anterior  and  posterior  walis,  or  extends  to  the  whole  surface 
of  the  tube.  When  the  woman  is  on  foot,  or  seated,  she  has  a feeling 
of  weight  and  uneasiness  about  the  ostium  vaginae  and  at  the  fun- 
dament ; dragging  sensations  in  the  lumbar  region,  and  various  in- 
convenient feelings,  that  partially  vanish  after  lying  down  a few 
moments.  Where  the  falling  is  complete,  to  the  symptoms  now 
mentioned  are  added  a discharge  of  puriform  mucus,  and  obstinate 
constipation,  with  a sort  of  urinary  tenesmus,  and  even  positive  stran- 
gury. The  action  of  the  urine  on  the  surface  of  the  tumour  pro- 
truded beyond  the  vulva,  and  the  friction  of  the  part  produced  by 
exercise  in  walking,  often  cause  a severer  degree  of  inflammation, 
painful  excoriations,  a sense  of  tension  extending  towards  the  region 


INVERSION  OF  THE  VAGINAL  MUCOUS  MEMBRANE.  211 

of  the  kidneys,  or  even  gangrene,  from  the  great  swelling  and  stran- 
gulation of  the  tumour  at  the  point  where  it  issues  from  the  vulva. 
Heister  relates  a case  that  shows  that  gangrene  may  follow  upon 
fruitless  manoeu  vres  made  for  the  purpose  of  reducing  a vaginal  pro- 
lapsus ; and  Loder,  in  his  journal,  quotes  a case  from  Stoeller,  going 
to  show  that  calculous  concretions  may  he  deposited  from  the  urine 
in  the  infiltrated  mucous  tissue  of  the  prolapsed  vaginal  membrane. 

This  disorder  not  only  proves  very  troublesome  and  obstructive 
during  labour,  but  may  even  become  dangerous.  Piesch*  states  that 
in  such  a case  the  tumour  projected  five  inches ; and  the  position  of 
the  child  having  rendered  it  necessary  to  turn,  the  consequence  was 
a laceration,  from  which,  however,  the  woman  soon  recovered. 
Lodert  informs  us  that,  in  another  case,  the  vagina  fell  every  time 
the  woman  was  confined,  and  made  a tumour  as  large  as  a man’s 
head.  The  accoucheur  always  succeeded  in  extracting  the  child 
with  the  forceps,  taking  care  to  support  the  prolapsed  parts.  Where 
this  is  found  to  be  impossible,  Richterf  advises  that  an  incision  be 
made  upon  the  lateral  part  of  the  procident  tumour,  and  adds  that 
such  an  operation  is  to  be  less  dreaded,  inasmuch  as  the  vagina  has, 
in  similar  circumstances,  been  ruptured  without  any  serious  conse- 
quences. 

[I  had  a case  where  the  vagina  prolapsed  at  least  five  inches,  and  was  as 
large  as  my  arm.  When  labour  came  on,  it  was  drawn  within  the  vulva, 
and  the  child  was  soon  safely  born. — M.] 

Where  the  inversion  is  complete,  the  shape  and  volume  of  the 
tumour  vary  in  some  instances  so  greatly  as  to  render  the  diagnosis 
extremely  difficult.  Bartholin, § Hagendorn||  and  SchacherIF  report 
Some  curious  instances  in  point ; and  the  last-named  author  quotes 
Widman  for  a case  of  prolapsion  of  the  vagina,  which,  from  its  pyri- 
form shape,  was  mistaken  for  a prolapsus  uteri,  until  it  was  disco- 
vered, upon  dissection,  that  the  tumour  was  formed  by  the  internal 
lining  membrane  of  the  vagina.  To  avoid  making  such  mistakes,  it 
is  only  necessary  to  reflect,  that  in  complete  inversion,  the  tumour,  of 
a reddish  colour,  of  an  oval  or  cylindrical  shape,  and  soft  consistence, 
has  circular  rugse  or  wrinkles,  and  is  thicker  at  its  lower  part  than 
anywhere  else.  It  should  also  be  remembered,  that  in  the  centre  of 
the  projecting  mass  is  a hole  large  enough  to  admit  the  finger,  which, 
upon  passing  upwards  sufficiently  far,  encounters  the  os  uteri. 

The  pi'ognosis  of  the  disorder  in  question  is  generally  not  bad, 
though  it  is  rare  to  obtain  a perfect  cure,  where  the  prolapsion  is 
complete,  and  particularly  where  the  whole  circumference  of  the 
vaginal  membrane  composes  the  tumour.  Yet  such  a fortunate  result 
has  been  known  to  succeed  to  an  inflammation  brought  on  by  the 
presence  of  a pessary  in  the  vagina.  Moraud  has  reported  such  an 

* Journal  de  Med.,  t.  iii.  f Journal,  t.  i.  490. 

\ Biblioth.  und  Aufang.  der  Wundaetzn,  b.  vii.  cap.  iv. 

§ Casus  Pudendi  Mulieb.  monstrose  conform.,  centur.  v.  hist.  9. 

| Procidentia  Uteri  instante  partii,  cent.  iii.  obs.  3. 

t Prog,  de  Prolapsu  Vaginse  Uteri. 


212 


INVERSION  OF  THE  VAGINAL  MUCOUS  MEMBRANE. 


instance  in  the  memoirs  of  the  Academy  of  Surgery , and  Schacher 
(De  Prolapsu  Vug.  Uter.)  makes  mention  of  a woman  who,  for  the 
cure  of  an  inverted  vagina,  introduced  within  it  a small  porcelain 
cup,  which  remained  a year  in  the  part,  and  was  extracted  with 
severe  distress,  and  then  not  until  it  was  broken  to  pieces,  so  violent 
was  the  inflammation  which  it  excited;  but  this  occurrence,  at  first 
deemed  so  prejudicial  to  the  woman,  effected  a perfect  cure,  which 
had  by  no  means  been  looked  for. 

The  treatment  in  simple,  incomplete  prolapsus,  consists  in  the 
use  of  antiphlogistics,  especially  as  local  applications,  and  continued 
until  the  inflammatory  symptoms  are  overcome.  Should  there  be 
some  special  cause  of  the  inflammation,  and  dependent  on  a state  of 
the  constitution,  recourse  should  be  had  to  an  appropriate  treatment; 
and,  indeed,  such  is  the  only  state  in  which  general  remedies  are  of 
any  use.  Whether  the  treatment  may  have  begun  with  the  reduction 
of  the  tumour,  or  whether  it  may  have  been  deemed  preferable  to 
wait— a better  plan — until  the  local  phlogosis  and  swelling  have  dis- 
appeared, we  should,  in  this  stage,  merely  make  use  of  tonic  and 
astringent  lotions  and  injections.  A decoction  prepared  conformably 
to  the  following  formula,  perfectly  fulfils  the  indication  : 

Take  of  yellow-bark,  in  powder,  and  of  oak-bark,  bruised,  of  each  three  drachms  ; 
boil  them  in  half  a bottle  of  claret ; add  of  sulphate  of  alumina  two  drachms,  and  filter 
the  liquor. 

This  mixture  should  be  used  at  first,  diluted  with  an  equal  quantity 
of  water;  then  a third,  and  afterwards  a fourth  part  of  water,  and, 
at  length,  without  any  dilution.  To  add  to  the  efficacy  of  the 
remedy,  recourse  might  be  had  to  exutories,  and  particularly  to  the 
formation  of  small  issues;  or  to  some  moxas  to  the  sacrum,  as  practised 
by  Baron  Larrey.  Except  where  the  relaxation  is  excessive,  under 
a well-managed  treatment  of  this  kind,  the  use  of  the  pessary,  to 
support  the  membrane,  would  be  rarely  found  necessary. 

In  a complete  falling  of  the  whole  circumference  of  the  vaginal  mem- 
brane, the  reduction  should  be  effected  as  soon  as  possible,  always 
taking  care,  by  proper  measures,  to  combat  the  inflammation  and 
swelling,  before  we  attempt  to  replace  the  parts  in  their  natural 
position.  Any  prospective  relaxation  and  displacement  of  the  mem- 
brane should  be  counteracted,  not  only  by  the  employment  of  tonic 
and  astringent  lotions,  such  as  we  have  above  mentioned,  in  speak- 
ing of  partial  and  incomplete  falling  of  the  vagina,  but  also  by  the 
introduction  of  sponges,  impregnated  with  the  same  liquid,  or  by 
small  sachets  filled  with  the  ingredients  of  the  lotions  in  question. 
A pessary  also  may  be  adjusted,  properly  adapted  to  the  form  of  the 
vagina,  and  left  in  situ  until  some  slight  inflammation  has  been 
excited,  as  in  Schachers  case,  before  cited,  and  which  might  serve  to 
procure  a radical  cure.  Should  the  prolapsed  membrane  exhibit 
large  gangrenous  eschars,  the  scarifications  recommended  by  Ilcis- 
ter*  could  be  productive  only  of  benefit.  In  such  a case,  and, 
indeed,  in  all  cases,  the  system  ought  to  be  invigorated  by  the  use  of 
cold  acidulous  chalybeate  waters,  as  those  of  Passy,  Spa,  Forges,  &c. 

• Inst.  Chir.  <le  Vulvae  Procidentia,  t.  ii.  cap.  cxlviii.  p-  1032. 


INVERSION  OF  THE  VAGINAL  MUCOUS  MEMBRANE. 


213 


Where  the  disorder  is  of  long  standing,  the  tumour  sometimes  be- 
comes irreducible,  or,  at  least,  its  reduction  is  very  difficult,  for  the 
prolapsed  membrane  groves  hard,  and  becomes  the  seat  of  excoria- 
tions and  even  of  ulcerations.  Under  such  unfavourable  circum- 
stances, we  ought,  as  far  as  possible,  to  endeavour  to  lessen  the  pain 
and  distress  by  advising  her  to  support  the  displaced  parts  with  a com- 
press, spread  with  opiated  cerate,  kept  in  place  by  a suspensory  and 
a T bandage. 

The  celebrated  accoucheur  Levret,*  and  also  M.  Hoin,t  of  Orleans, 
inform  us  that  by  rest  and  the  dorsal  decubitus,  they  succeeded  so  far 
in  reducing  a tumour  that  projected  to  the  distance  of  seven  inches, 
that  after  a month,  under  the  treatment,  the  remainder  of  the  tumour 
was  reduced.  Richterf  advises  the  reduction  of  the  vaginal  prolapsus, 
where  the  case  is  a difficult  one,  by  the  method  followed  by  some 
authors,  in  treating  large  omental  hernias.  This  consists  in  making 
the  woman  lie  on  her  back,  with  the  thighs  drawn  somewhat  up- 
wards, and  then  keeping  up  a gentle  compression  of  the  tumour, 
while  a long  course  of  diet  is  prescribed,  with  the  administration  of 
mercurial  purgatives. 

M.  Dieffenbach,  instead  of  resting  content  with  merely  reducing 
the  tumour  and  keeping  it  reduced  by  means  of  a pessary,  supposed 
that  Dupuytren’s  plan  for  treating  prolapsus  of  the  rectum  might  be 
adopted. 

That  distinguished  Berlin  surgeon,  after  reducing  the  tumour, 
exscinds,  by  means  of  a forceps  and  scissors,  all  the  loose  folds  of  the 
inner  surface  of  the  labia  pudendi.  The  operation,  which  is  easily 
performed,  should  be  so  conducted  that  the  folds,  as  they  are  re- 
moved, should  constitute  so  many  radii  converging  to  the  centre  of 
the  vagina,  so  as  to  allow  the  upper  end  of  each  one  to  terminate 
about  one  inch  within  the  orifice  of  the  canal.  The  after  treatment 
consists  in  merely  cleansing  the  parts  once  a day,  or  if  it  be  deemed 
desirable  to  make  them  suppurate,  in  introducing  a fascicle  of  lint,  the 
base  of  which,  being  divided  into  rays,  would  furnish  a small  fasci- 
culus to  each  one  of  the  little  incisions.  The  end  proposed  in  this 
operation,  is  to  contract  the  ostium  vaginae,  which  thus  acquires  the 
desirable  resisting  power.  To  arrive  at  the  same  result,  Messrs. 
Marshall  and  Hemirig  have  successfully  adopted  a mode  that  con- 
sists in  exscinding  a large  elliptical  lamina  of  the  mucous  membrane, 
and  immediately  uniting  the  wound  by  suture.  This  mode,  both 
difficult  and  painful,  appears  to  us  less  suitable  than  Dieflenbach’s.  . 

Should  the  patient  absolutely  ask  to  be  relieved  of  her  disgusting 
deformity,  where  the  reduction  is  impossible  from  the  transformation 
and  degeneration  of  the  tumour,  there  is  no  other  method  of  proceed- 
ing than  the  amputation  of  the  extensive  mass  of  membrane,  which, 
according  to  Stalpaart  Van  der  Wiel,§  J.  A.  Meckren,||  and  other 
writers,  has  been  successfully  done  in  similar  cases.  In  deciding  upon 

* Mem.  de  l’Acad.  de  Chir.,  t.  ii. 
t Essai  sur  les  Hernies  rares  et  peu  connues. 
t Biblioth.  und  Aufang.  der  Wundaetzn,  b.  vii.  cap.  iv. 

§ Observ.  Rariores  Medecin.,  t.  ii.  1 Observ.  Chir.,  obs.  45. 


214 


INVAGINATION  OF  T^IE  VAGINA. 


this  extreme  measure,  as  in  M.  Berard,  jun.’s,  instance,*  it  would  be 
requisite,  previous  to  any  operation,  not  only  to  make  sure  of  the 
state  of  the  bladder  and  rectum,  but  also  to  endeavour  to  learn  that 
the  vagina  alone  is  prolapsed,  and  that  the  womb  is  not  compre- 
hended in  the  mass.  And  lastly,  Boyer’s  advice  should  be  followed, 
not  lightly  to  resolve  upon  this  operation,  which  is  far  from  being 
free  from  danger. 

We  may  not  close  this  article  without  remarking,  that  a falling  of 
the  lining  membrane  of  the  vagina  must  not  be  confounded  with  in- 
vagination of  that  canal;  a case  whose  character  is  displayed  in  the 
following  chapter. 


INVAGINATION  OF  THE  VAGINA. 

Invagination  of  the  vagina  consists  in  a displacement  of  the  upper 
parietes  of  the  tube,  which,  being  gradually  carried  downwards  by 
the  womb,  in  a prolapsed  state,  become  intussuscepted  in  a part  of 
the  vagina  nearer  to  the  vulva.  There  are  different  stages  of  this 
prolapsus  that  it  is  well  to  explain.  In  the  first  stage  we  find,  at  the 
orifice  of  the  vulva,  a sort  of  cushion,  in  irregular  folds,  more  or  less 
protruding,  in  the  centre  of  which,  upon  Touching,  we  find  the  os 
tincoe,  which  is  always,  in  this  stage,  lower  than  natural.  The  softish 
red  circle,  formed  by  the  invagination  of  the  superior  portion  of  the 
vagina,  is  found  to  be  less  projecting  and  voluminous  after  some 
time  resting  in  a horizontal  posture,  but  it  increases  and  becomes  far 
more  apparent  in  a vertical  posture,  giving  rise  not  only  to  a distress- 
ing weight  about  the  groins  and  hypogastrium,  but  also  to  a painful 
tenesmus  and  dysury,  proceeding  from  the  change  in  the  direction  of 
the  urethra. 

In  the  second  and  third  stage,  the  tumour,  now  more  elongated 
and  cylindrical,  exhibits,  as  it  does  in  the  first,  an  irregular  opening 
at  its  lower  end,  the  orifice  of  a narrow  passage,  at  the  bottom  of 
which  is  the  os  uteri. 

In  some  cases  of  invagination  of  the  vagina,  the  neck  of  the  womb 
is  found  to  be  considerably  elongated,  but  it  is  a difficult  matter  to 
decide  which  of  these  lesions  is  the  cause  of  the  other.  In  fact,  if  we 
may,  on  the  one  hand,  suppose  the  elongation  and  hypertrophy  of 
the  cervix  to  be  the  cause  of  the  uterine  prolapsus  and  consequent 
invagination,  we  may,  on  the  other,  aver  that  the  cervix  has  be- 
come elongated  since  the  occurrence  of  the  prolapsus,  by  extending 
gradually  in  a direction  wherein  it  met  with  no  resistance ; the  body 
of  the  organ  being  meanwhile  retained  at  a certain  elevation  by  its 
natural  ligaments  and  attachments. 

The  vaginal  invagination  is  generally  looked  upon  by  modern 
authors  as  a lesion  secondary  to,  and  symptomatic  of,  the  prolapsus 
of  the  womb,  which  is  its  determining  cause. 

Where  the  complaint  is  of  long  standing,  and  especially  if  the 
woman  has,  for  a long  time,  had  no  assistance,  the  cushion  becomes 

* Velpeau,  Elements  de  Medecine  Operatoire,  t.  iii.  p.  590. 


CONTUSION  OF  THE  LABIA. 


215 


engorged,  the  tumour  is  elongated  and  acquires  a harder  consistence, 
but  still  has  an  opening  below,  through  which  the  menses  are  dis- 
charged as  if  through  the  os  tincae  at  each  menstrual  period.  In 
fine,  the  projection  formed  by  the  invagination  resembles,  in  shape 
and  colour,  the  cervix  of  the  womb  when  completely  prolapsed,  so 
much  so,  indeed,  as  to  have  deceived  several  practitioners,  among 
whom  I may  mention  the  names  of  Bartholin,  Widman,  and  Job  a 
Meckreen.  It  is  unnecessary  to  observe,  that  with  the  least  attention, 
it  is  easy  to  avoid  falling  into  such  mistakes. 

Invagination  of  the  vagina  differs  from  the  tumefaction  and  fall 
of  the  lining  membrane,  in  this,  that  it  can  only  commence  at  the 
superior  extremity  of  the  canal  and  near  to  the  collum  uteri, 
while  the  inversion  of  the  mucous  membrane  may  occur  at  any 
part  of  its  length.  In  invagination  the  finger  is  carried  up  to  thd 
womb,  and  ascertains  that  the  bottom  of  the  vagina,  being  doubled  on 
itself,  or  folded,  still  accompanies  the  womb,  which  is  always  dis- 
placed ; in  the  other  case,  or  prolapsus  of  the  internal  coat,  the  index, 
when  introduced  betwixt  the  cushion  and  the  circumference  of  the 
opening,  is  arrested  by  the  fold  composed  of  the  relaxed  mucous 
membrane  as  it  descends,  in  order  to  escape  through  the  os  exter- 
num. Finally,  invagination  always  accompanies  prolapsus  uteri, 
whereas,  inversion  of  the  membrane  is  generally  independent  of  any 
uterine  displacement. 

The  tumour  arising  from  the  lesion  under  consideration  is  liable 
to  become  inflamed,  to  ulceration,  and  the  consequences  that  may 
flow  from  such  affections.  The  means  of  preventing  or  remedying 
these  evil  consequences,  are,  as  soon  as  possible,  to  replace  the  pro- 
lapsed parts,  and  keep  them  reduced  by  a pessary ; and  the  other 
resources  we  have  already  pointed  out  in  our  remarks  upon  falling 
of  the  womb.  By  curing  the  disorder  just  mentioned,  we  put  an 
end  to  that  of  the  vagina,  which  is  the  consequence  of  it. 


SECTION  THIRD. 

CHAPTER  VII. 

PHYSICAL  LESIONS. 

To  facilitate  the  study  of  the  physical  lesions  of  the  external  and 
internal  genital  organs  of  the  female,  we  divide  them  into  three 
classes,  which  are  : 

1.  Contusions,  wounds  and  lacerations  of  the  vulva,  perineum, 
vagina  and  uterus ; ruptures  of  these  organs ; and  finally  contusions 
and  wounds  of  the  mammae  ; 

2.  Vesico-vaginal,  utero-vaginal  and  recto-vaginal  fistulas; 

3.  The  accidental  introduction  of  foreign  bodies  into  the  genital 
cavities. 


216 


CONTUSION  OF  THE  LABIA. 


CONTUSION  OF  THE  LABIA  MAJORA. 

From  their  situation  at  the  inferior  extremity  of  the  trunk,  the 
external  sexual  parts  which  protect  and  circumscribe  the  vulva,  to  wit, 
the  mons  veneris,  the  labia  majora  and  the  perineum,  are  exposed 
to  contusions,  to  wounds  and  to  lacerations  which  may  result  either 
from  a fall,  from  a wound,  or  a blow ; from  the  first  attempts  at  sexual 
intercourse;  or  from  the  "effects  of  criminal  copulation.  The  disor- 
ders depending  upon  the  latter  cause  are  the  more  severe  in  propor- 
tion to  the  resistance  the  female  has  made;  the  disproportion  between 
the  genital  organs  of  the  two  sexes ; whether  the  violence  have  been 
exerted  upon  a virgin  girl ; and  especially  whether  she  be  still  far 
from  her  full  development.  *** 

The  loose  texture  of  the  cellular  tissue  of  the  labia  majora  causes 
these  two  folds  frequently  to  become  the  seat  of  ecchymoses  and 
sanguine  infiltrations,  developed  under  the  influence  of  the  causes 
which  we  have  just  enumerated,  and  most  frequently  after  a more 
or  less  laborious  labour.  Assisted  by  the  depending  position  of  the 
vulva,  the  tumefaction  soon  becomes  considerable,  and  the  parts 
assume  a livid,  a deep  violet,  or  almost  black  colour;  yet  it  seldom 
happens  that  the  contusion  is  severe  enough  to  determine  gangrene ; 
it  frequently  does  not  even  form  an  abscess,  and  then  we  find  the 
extravasated  blood  become  rapidly  absorbed,  and  the  swollen  organs 
soon  regain  their  natural  colour  and  volume. 

When  the  contusion  is  slight,  and  produces  only  a simple  ecchy- 
mosis,  we  should  restrict  ourselves  to  the  employment  of  some  re- 
solvent topical  application,  such  as  compresses  wet  with  Goulard’s 
extract,  or  even  with  cold  water  alone,  to  which  we  might  add  for 
every  glassful  of  the  fluid  a spoonful  of  vinegar  or  Cologne  water. 
In  order  to  retain  these  resolvent  applications,  and  especially  to  aid 
their  absorption,  we  may  have  recourse  to  steady  pressure  made  by 
means  of  a bandage  fitted  to  the  parts. 

If  the  contusion  have  been  violent,  and  especially  if  there  results 
from  it  a considerable  effusion  of  blood,  we  should  order  an  appli- 
cation of  leeches  around,  but  not  on  the  ecchymosed  spots ; and 
afterwards  follow  the  same  plan  as  we  indicated  above.  Where 
compression  has  not  been  used  in  the  beginning,  or  where  it  cannot 
be  borne  on  account  of  the  pain  it  produces,  we  have  a good  substi- 
tute in  the  use  of  resolvent  and  emollient  cataplasms,  made  of  rice 
Hour  boiled  in  decoction  of  marshmallow,  or  of  flax-seed  meal  and 
infusion  of  roses,  with  the  addition  of  a little  red  wine  or  a teaspoon- 
ful  of  lead  water.  The  first  of  these  cataplasms,  which  should  be 
enclosed  in  gauze,  is  commonly  preferred  by  the  patient,  because  it 
does  not  soil  their  linen,  and  the  parts  upon  which  it  is  applied. 

The  employment  of  all  these  remedies  should  be  suspended,  if  the 
tumour,  having  rapidly  acquired  greater  size,  were  to  become  the 
seat  of  inflammatory  symptoms  announced  by  more  acute  pain,  by 
uniform  redness,  by  heat  and  tension  of  the  skin.  Recourse  should 


RUPTURE  OF  THE  PERINEUM. 


217 


then  be  had  to  emollient  and  maturative  applications,  in  order  to 
favour  the  suppuration  about  to  be  established,  and  which  is  mani- 
fested particularly  by  rigors  and  by  increased  pain.  When  fluc- 
tuation has  become  evident,  the  tumour  should  be  freely  opened 
in  order  to  give  ready  issue  to  the  blood  and  pus.  The  after 
treatment  should  be  like  that  employed  after  the  opening  of  other 
abscesses ; that  is  to  say,  the  use  of  emollient  cataplasms,  and  when 
the  signs  of  inflammation  have  nearly  disappeared,  the  use  of  mild 
discutients,  in  order  to  hasten  the  disengorgement  of  the  part  and  the 
cicatrization  of  the  wound. 

OF  RUPTURE  OF  THE  PERINEUM  AND  THE  MEANS  OF  REMEDYING  IT. 

Though  the  wounds  and  lacerations  which  may  result  from  the 
action  of  cutting  or  puncturing  instruments  upon  the  labia  majora, 
require  for  their  treatment  only  the  means  employed  for  wounds  in 
other  parts  of  the  body,  there  is  one  kind  of  solution  of  continuity  to 
which  these  two  pudendal  folds  are  much  more  frequently  exposed, 
and  which,  for  this  reason,  requires  us  to  treat  of  it  more  in  full.  The 
lesion  to  which  we  refer  is  the  laceration  of  the  posterior  commissure 
of  the  labia  majora,  which  takes  place  sometimes  in  the  most  natural 
labours,  but  much  more  frequently  when  the  woman  is  delivered 
without  assistance,  or  after  imprudent  operations,*  or  awkward  at- 
tempts at  traction  .with  the  forceps. 

When  the  laceration  is  confined  to  the  fourchette  or  posterior  com- 
missure of  the  vulva,  the  accident  never  produces  any  serious  con- 
sequences, because,  by  means  of  rest,  and  by  bringing  the  thighs 
properly  together,  the  reunion  and  cicatrization  of  the  parts  soon 
occur  spontaneously;  sometimes,  indeed,  the  same  thing  happens 
from  the  efforts  of  nature  alone,  even  when  the  laceration  has  ex- 
tended far  upon  the  perineum. 

Unfortunately,  the  same  result  does  not  follow  when  the  sphincter 
of  the  anus  and  the  rectum  are  comprised  in  the  solution  of  conti- 
nuity. The  edges  of  so  extensive  a division  being  always  irregular, 
dentated  and  puckered,  as  it  were,  unite  with  difficulty  by  the  first 
intention:  besides,  the  constant  flow  of  the  lochia  acts  to  prevent  it; 
whence  it  happens  that  the  surfaces  of  each  lip  of  the  wound,  after 
having  suppurated  for  a long  time,  end  by  cicatrizing  separately,  and 
the  opening  of  the  vulva  is  thus  enlarged  in  proportion  to  the  extent 
of  the  laceration.  The  solid  and  liquid  matters  now  escape  involun- 
tarily, and  the  absence  of  the  support  which  the  perineum  lends  to  the 
neighbouring  parts,  becomes  a cause  of  procidentia  of  the  vagina,  or 
of  prolapsus  of  the  womb  ; finally,  this  disgusting  infirmity  not  only 
renders  the  woman  insupportable  to  herself,  but  often  gives  rise  to 
conjugal  difficulties  which  may  have  the  most  unhappy  conse- 
quences. 

* Dr.  Boudet  (Theses  de  la  Faculte  de  Med.  de  Paris)  reports  cases  of  rupture,  or 
rather  of  division  of  the  perineum,  by  means  of  a sixpence.  This  method,  as  absurd 
as  barbarous,  was  employed  by  an  ignorant  midwife,  for  the  purpose  of  augmenting 
the  diameter  of  the  vulva,  and  thus  facilitating  the  escape  of  the  child. 


218 


RUPTURE  OF  THE  PERINEUM. 


To  prevent,  as  far  as  possible,  the  terrible  accidents  which  we 
have  just  enumerated,  it  is  necessary  to  support  the  perineum  with 
the  hand  at  the  moment  that  the  head  of  the  child  distends  the  vulva, 
in  such  a way  as  to  force  the  head  to  rise  towards  the  pubis,  but  not 
to  prevent  its  descent.  It  is  equally  important,  as  soon  as  the  parie- 
tal protuberances  have  passed  beyond  the  tuberosities  of  the  ischia, 
to  tell  the  woman  to  moderate  her  expulsive  efforts,  particularly  if 
the  labour  be  rapid,  and  no^  to  bear  down  more  and  more,  as  is  re- 
commended so  mal-a-propos  by  the  old  women,  by  the  midwives,  and 
by  most  obstetricians.  It  is  at  this  stage  of  the  labour  that  the  parts, 
in  some  sort  surprised , give  way  because  the  head,  too  violently 
propelled,  does  not  permit  them  to  yield  so  rapidly  and  to  mould 
themselves  upon  it.  The  chances,  therefore,  of  preserving  the  peri- 
neal septum  in  its  integrity,  will  be  the  greater,  in  proportion  as  the 
vulva  has  been  traversed  more  slowly.  If  it  be  not  in  the  power  of 
the  obstetrician  wholly  to  prevent  this  kind  of  laceration,  he  can 
always  prevent  its  extending  too  far,  which  is  extremely  important. 

[The  direction  to  support  the  perineum  above  given  is  insufficient;  it 
should  have  been  more  explicit,  as  I am  convinced  that  the  instruction  ill 
the  medical  schools  does  not  fully  inform  the  young  practitioner  of  the  mo- 
tive for  the  rule.  The  direction  ought  to  be,  to  press  the  perineum  in  such 
a way  as  to  make  the  head  turn  upwards  in  front  of  the  symphysis  in  pro- 
portion as  it  emerges  more  and  more  from  the  pelvis.  It  should  be  to  cause 
the  head,  by  supporting  it,  to  move  in  coincidence  with  Professor  Cams’ 
circle.  Now,  Cams’  circle,  is  a circle  whose  radius  equals  the  semi-dia- 
meter of  the  pelvis,  measured  from  front  to  rear.  To  draw  this  circle,  take 
a pelvis  and  saw  it  through  at  the  pubis  and  sacrum  so  as  to  divide  them 
vertically.  Set  one  leg  of  a compass  on  the  posterior  margin  of  the  cut  sur- 
face of  the  symphysis,  open  the  other  leg  to  half  the  diameter  of  the  excava- 
tion, and  with  that  leg  describe  a circle  in  the  pelvis.  This  is  Cams’  circle, 
and  it  indicates  the  curved  axis  of  the  pelvis.  It  is  along  this  axis  that  the 
centre  of  the  head  moves  as  it  is  born;  and  to  hold  the  perineum,  means, 
to  make  it  move  until  it  is  born,  in  coincidence  with  that  line.  When  this 
is  properly  done,  lacerations  of  the  perineum  rarely  occur. — M.] 

Cases  have  been  seen  of  women  delivered  without  aid,  in  whom 
the  child  has  passed  through  an  opening  in  the  perineum,  without 
lesion  of  the  fourchette  or  anus.  Professor  Moreau,  who  has  treated 
of  this  subject  before  the  Academy  of  Medicine,  affirms  that  the 
annals  of  science  contain  more  than  thirty  facts  of  this  kind  well 
established,  and  observed  some  in  France,  others  in  foreign  coun- 
tries.* M.  Deneuxt  has  likewise  reported  the  case  of  a woman  in 
whom  the  placenta  was  extracted  through  the  perineum,  the  vulva 
scarcely  permitting  the  introduction  of  the  finger ; in  another  female, 
after  a rupture  of  this  kind,  there  existed  a prolapsus  of  the  uterus 

* Seance  de  l’Acad^mie  de  Medecine  du  16  Octobre,  1832. 

•j-  Seance  de  l’Acad^mie  de  Medecine,  meme  jour,  et  merne  annee. 


RUPTURE  OF  THE  PERINEUM. 


219 


through  the  perineal  opening:  finally,  in  the  early  part  of  October, 
1832,  we  saw  at  the  Hotel-Dieu,  at  Paris,  Salle  St.  Jean,  No.  1,  a 
woman  who  had  been  spontaneously  delivered,  in  whomthe  escape 
of  the  infant,  at  term  had  taken  place  through  a laceration  of  the  peri- 
neum, without  lesion  of  the  posterior  commissure  of  the  labia  majora 
or  of  the  anus.  The  labour  had  lasted  only  four  hours;  the  symphy- 
sis and  the  pubic  arch  were  properly  formed. 

It  has  sometimes  happened  even  when  a central  perforation  of  the 
perineum  has  been  produced,  that  the  foetus  has  nevertheless  passed 
out  through  the  vulva,  the  edges  of  which  have  remained  perfect. 
Madame  Lachapelle,  who  has  seen  and  reported  several  such  cases, 
assures  us  that  if  the  women  had  not  been  uncovered,  and  the 
sexual  organs  exposed  to  view,  she  might  have  supposed  that  the 
child  had  passed  through  the  perineal  rupture ; and  she  thinks  it 
probable  that  the  same  thing  has  occurred  in  the  greater  part  of  the 
cases  reported  by  authors.  Yet,  notwithstanding  the  opinion  of 
Madame  Lachapelle,  we  cannot  doubt  that  the  foetus  has  sometimes 
been  expelled  through  the  central  laceration  of  the  perineum.  Profes- 
sor Delpech  saw  this  rupture  take  place  at  the  left  and  posterior  side  of 
the  vagina,  and  extend  along  the  base  of  the  external  labium  of  the 
same  side,  which  was  in  this  way  detached  from  the  pubic  arch ; 
the  vulva  being  forced  to  the  right,  the  delivery  took  place  through 
the  accidental  perforation. 

[My  colleague,  Professor  Miilter,  informed  me  that  he  saw  a case  about 
three  years  since,  in  which  the  child’s  head  had  passed  through  a lacerated 
perineum,  and  the  head  being  delivered,  the  attendant  could  not  bring  down 
the  shoulder.  The  professor  being  called  in  on  account  of  the  difficulty, 
divided  the  anterior  band  or  edge  of  the  perineum,  whereupon  the  foetus  was 
immediately  born. — M.] 

Sometimes  the  laceration  extends  towards  one  of  the  thighs,  and 
exhibits  the  form  of  a capital  L ; in  other  cases  it  extends  towards 
both  thighs  at  the  same  time,  and  assumes  the  form  of  the  letter  T. 
Solutions  of  continuity  of  this  kind  usually  suppurate,  and  terminate 
most  generally  by  spontaneous  reunion,  forming  a solid  cicatrix. 
Such  has  been  the  result  in  the  cases  of  this  kind,  observed  and 
reported  by  Denman,  Baudelocque,  Desormeaux,  Delpech,  Dupuy- 
tren,  Madame  Lachapelle,  and  some  other  practitioners. 

The  custom,  which  is  so  common,  of  placing  a great  many  pillows 
under  the  head  and  shoulders  of  women,  during  the  progress  of 
labour,  is  one  of  the  causes  which  contribute  to  the  laceration  of  the 
perineum.  It  happens  in  this  way  that  the  trunk,  assuming  a nearly 
vertical  position,  the  weight  of  the  child,  and  particularly  its  head, 
compresses  the  perineal  septum  very  strongly,  and  the  expulsive 
efforts  of  the  womb  are  sometimes  sufficiently  powerful  to  force  the 
perineum  to  yield  by  bursting  it,  and  in  this  way  overcoming  the 
arrest  which  existed  in  consequence  of  the  vicious  position  of  the 
female. 


220 


RUPTURE  OF  THE  PERINEUM. 


This  unfortunate  accident,  which  occurs  with  great  facility  in 
women  in  whom  the  orifice  of  the  vagina  is  placed  very  much  in 
front,  and  almost  on  a level  with  the  bones  of  the  pubis,  might  gene- 
rally be  avoided  by  keeping  the  trunk  and  head  of  the  female  in  an 
almost  horizontal  position,  and  by  sustaining  the  perineum  during 
the  whole  of  the  labour  in  such  a way  as  to  lift  the  child’s  head  up- 
ward in  the  direction  of  the  symphysis  pubis. 

When  it  has  proved  impossible  to  prevent  the  laceration  of  the 
perineum,  we  should  seek  to  obtain  the  reunion  of  the  edges  of  the 
wound  by  causing  the  patient  to  lie  upon  her  side,  and  by  recom- 
mending her  to  keep  her  thighs  approximated  and  always  in  the  same 
position.  Though  this  means  be  often  without  avail,  we  should  never 
fail  to  put  it  in  practice,  because  it  has  sometimes  been  followed  by 
the  reunion  of  the  whole,  or  at  least  of  a portion  of  the  laceration ; an 
instance  of  which  M.  Sedillot,  jr.,  has  reported.*  When  these  pre- 
cautions and  first  attempts  at  reunion  fail,  and,  especially,  when  the 
cicatrization  of  the  lips  of  the  wound  is  complete,  there  remains  a 
resource,  which  is  sometimes  successful,  consisting  in  the  reunion 
by  several  points  of  suture.  This  operation,  already  performed  with 
success,  by  Forestus,t  Delamotte,f  Trainel  and  Noel,§  Saucerotte,|| 
Asdrubali,!  Dupuytren,**  Montain,tt  Emile  Barthelemi,ff  Dieffen- 
bach,§§  and  lately,  by  M.  Vidal  de  Cassis, ||||  has  been  fully  introduced 
into  surgical  practice,  through  the  brilliant  results  obtained  by  Pro- 
fessor Roux,  which  we  are  now  about  to  report  very  succinctly. 

The  first  patient  of  whom  we  shall  speak,  is  the  wife  of  a distin- 
guished physician  in  a small  provincial  town,  who  had  already  been 
operated  upon,  without  success,  for  a laceration  of  the  perineum 
communicating  with  the  anus,  the  result  of  a labour  terminated  by 
the  forceps.  The  first  operation  was  performed  in  the  month  of 
January,  1832,  with  the  twisted  suture;  but  the  union,  which  had  at 
first  seemed  complete,  was  only  apparent;  for  the  perineal  division 
soon  recurred  as  before. 

This  failure  discouraged  neither  the  patient  nor  her  husband,  and 
a new  attempt  was  resolved  upon,  with  still  greater  care,  and  with  a 
modification  of  the  mode  of  operating.  M.  Roux,  to  whose  care  the 
lady  had  been  confided,  having  reflected  upon  the  causes  of  the  fail- 
ure of  the  first  operation,  thought  that  the  greatest  obstacle  to  reunion 
was  the  impossibility  of  bringing  the  deep-seated  parts  into  exact 
contact  with  the  twisted  suture,  and  that  under  such  circumstances 

* Recueil  perioddque  de  la  Societe  roy.  de  Medecine  de  Paris,  tom.  vii. 

fDe  Morbis  Mulierum,  page  759. 

tTraite  Compl.  de  Chirurg.  cont.  observat.  405. 

§ Recueil  period,  de  la  Societe  roy.  de  Med.  t.  vii.  p.  187. 

||  Idem.  tom.  iv.  p.  117;  Melange  de  Chirurg.,  t.  ii. 

^ Tom.  ii.  p.  248. 

**  Le9ons  Orales  et  Lancette  Fran^aise  t.  vi.  n.  102.  p.  418. 

ff  Revue  Medicale,  annee  1821,  tom.  v.  p.  204. 

4$  Lancette  Franeaise,  t.  vi.  n.  104.  p 427. 

§§  Journal  Complcmentaire,  t.  38.  p.  193. 

1 11  Doctor  Vidal  de  Cassis  has  practised,  with  success,  in  two  cases,  the  suture  of 
the  perineum,  by  means  of  straight  needles  with  handles,  and  by  a simple  and  inge- 
nious process,  which  we  shall  describe  when  speaking  of  vaginal  fistulas. 


RUPTURE  OF  THE  PERINEUM. 


221 


the  quilled  suture  was  preferable,  because  its  action  extended  to  a 
greater  depth.  In  fact,  curved  needles  take  up  more  tissue  ; the  liga- 
tures penetrate  deeper,  and  the  pressure  of  the  cylinders  exposes  less 
to  danger  of  laceration,  and  is  more  equable ; he  had  to  fear,  therefore, 
neither  strangulation  nor  constriction  of  the  edges  of  the  wound;  con- 
sequently, the  chances  of  success  were  much  greater.  In  the  second 
operation,  in  which  the  edges  of  the  laceration  were  freshened  as  be- 
fore, two  or  three  arterioles  bled  and  were  tied;  four  points  of  suture 
were  placed  so  as  to  involve  the  parietes  of  the  vagina,  but  to  a vury 
slight  depth,  in  order  to  avoid  eversion  of  the  labia,  which  would 
have  placed  in  contact  two  mucous  membranes,  which  unite  with 
the  greatest  difficulty ; a gum-elastic  bougie  formed  the  cylinder, 
and  the  ligatures  were  strongly  tied  ; the  coaptation  was  now  perfect 
upon  the  interior,  but  not  on  the  exterior,  where  the  edges  of  the 
wound  formed  a projection ; the  coaptation  was  made  complete  by 
means  of  five  ligatures  placed  in  the  intervals ; the  ligatures  were 
not  cut,  nor  the  needles  removed,  until  six  days  had  elapsed  ; abso- 
lute diet  was  prescribed,  and  the  most  assiduous  attentions  paid. 

It  was  not  until  the  twenty-second  day  that  the  patient  went  to 
stool,  and  passed  faeces  so  consistent  that  it  was  necessary  to  aid  the 
defecation  by  means  of  the  fingers  introduced  into  the  vagina ; but 
by  this  time,  the  cicatrix  was  sufficiently  strong  to  resist  the  strain. 

A puriform  discharge  appeared  from  both  the  vagina  and  the  anus, 
but  there  was  neither  haemorrhage  nor  pain. 

There  now  remained  only  a small  opening  at  the  anus,  which 
suppurated:  a tent  was  introduced  into  the  rectum;  the  consolida- 
tion was  soon  perfect;  the  raphe  became  linear  and  solid,  but  there 
remained  a small  recto-vaginal  fistula,  which,  with  difficulty,  admit- 
ted the  introduction  of  the  extremity  of  the  little  finger.  This  fistula 
gave  issue  to  some  gas,  without  allowing  of  the  escape  of  any  sterco- 
raceous  matter.  M.  Roux  heard,  some  time  after,  through  a letter 
from  the  husband,  that  the  journey,  undertaken  on  the  fifth  day  after 
first  leaving  the  bed,  had  not  occasioned  any  accident,  and  that  the 
fistulous  point  which  existed  between  the  rectum  and  vagina  had 
ceased  to  suppurate  two  months  before,  and  was  cicatrized.  The 
patient  recovered  perfectly;  her  perineum  presents  the  ordinary  thick- 
ness and  firmness,  and  the  most  practised  eye  could  detect  no  trace 
of  the  operation.  As  soon  as  the  suppuration  had  ceased,  the  sexual 
congress  took  place,  at  first  with  great  care,  and  finally  without  any 
kind  of  precaution.  This  lady  has  regained  her  natural  complexion 
and  spirits. 

This  perineal  suture  (the  first  performed  by  M.  Roux,)  was  the 
subject  of  a paper  read  before  the  Academy  of  Medicine,  on  the  30th 
October,  1832.  The  case  is  published  in  the  number  of  the  Lancette 
Frangciise  for  the  first  of  November  of  the  same  year. 

The  second  case  is  taken  from  the  clinic  of  La  Charite.  The  wo- 
man who  was  the  subject  of  it  was  Pauline  Evrard,  aged  22  years,  a 
housemaid,  and  entered  the  hospital  March  15,  1833,  in  No.  24  of  the 
Salle  Ste-Catherine. 

This  person,  enjoying  good  health,  having  become  pregnant  in 


222 


RUPTURE  OF  THE  PERINEUM. 


1831,  entered  the  Maternite  a month  before  her  delivery,  where  she 
had  so  laborious  a labour  that  it  was  followed  by  the  laceration  of 
the  perineum.  Notwithstanding  this  infirmity,  she  again  became 
pregnant ; and  her  labour,  though  still  difficult,  was  much  Jess  so 
than  on  the  first  occasion.  Some  time  after  this  last  lying-in,  Pau- 
line was  admitted  into  La  Charite,  where,  during  the  first  eight  days 
after  her  entrance,  she  was  put  upon  very  strict  diet  and  the  use  of 
diluents.  On  the  22d  of  March  a purgative  was  administered; 
finally,  on  Saturday  the  23d  of  March,  M.  Roux  proceeded  to  the 
operation,  which  was  conducted  in  the  following  manner: 

From  the  two  surfaces  of  the  wound  a thin  segment  of  tissue  was 
removed,  so  that  by  approximating  the  two  edges  of  the  division, 
reunion  might  readily  take  place.  Three  sutures  were  introduced, 
one  near  the  anus,  another  near  the  vulva,  and  the  third  between  the 
two  first.  These  three  points  each  comprised  a portion  of  the  vagina, 
for  the  purpose  of  avoiding,  at  the  same  time,  any  gaping  of  the 
wound  exteriorly,  and  any  effusions  of  purulent  matter  upon  the  inte- 
rior. To  form  the  loops  on  one  side,  the  ligatures  were  cut  and  tied, 
and  between  the  two  ends  thus  knotted,  a piece  of  gum-elastic  was 
placed  and  drawn  tight  by  the  other  ends.  Between  these  last,  a 
second  piece  of  gum-elastic  was  placed  and  tied  with  a knot.  Two 
days  after  the  operation,  the  patient  had  retention  of  urine,  which 
required  the  introduction  of  a catheter  into  the  bladder,  which  was 
left  there ; this  allowed  the  urine  to  flow  off  as  fast  as  it  was  brought 
to  the  bladder ; but  two  days  elapsed  before  it  was  deemed  proper 
to  solicit  an  alvine  evacuation  by  the  administration  of  a mild  purga- 
tive dose  of  calomel,  ten  grains.  The  matters  discharged  passed  alto- 
gether by  the  rectum,  and  not  at  all  by  the  vagina,  ahhough,  during 
a fortnight,  the  patient  could  perceive  that  in  voiding  gas,  a portion 
escaped  through  the  vagina.  Pledgets  spread  with  cerate,  and  intro- 
duced between  the  lips  of  the  wound,  in  a short  time  entirely  obli- 
terated the  communication  which  existed  between  the  rectum  and 
the  canal  of  the  vagina,  and  the  foecal  matter,  as  well  as  the  gas, 
escaped  only  through  the  anus.  The  patient  recovered  perfectly,  the 
only  thing  remaining  being  a slight  contraction  of  the  orifice  of  the 
vagina. 

If  the  suture  of  the  perineum,  which  was  performed  with  success 
by  Dupuytren,  twenty-five  years  since,  (see  our  note,  p.  77,)  has 
frequently  been  employed  without  advantage,  it  is  because,  in  the 
greater  number  of  cases,  the  operation  has  been  performed  too  soon. 
As  it  is  very  uncommon  for  the  lips  of  the  wound  to  be  in  a condi- 
tion favourable  to  immediate  reunion,  it  is  much  better  to  postpone 
the  operation.  We  are  so  convinced  of  the  advantage  of  waiting,  that 
we  fear  not  to  say  that  success  would  be  almost  certain,  if  the  ope- 
ration could  be  deferred  until  suppuration  had  produced  disengorge- 
inent  and  contraction  of  the  edges  of  the  laceration,  and  especially 
until  the  lochia  were  completely  suppressed,  or,  at  least,  very  much 
diminished.  In  fact,  it  is  the  escape  of  this  fluid  which  more  than 
any  thing  else  hinders  the  reunion  of  the  wound,  and  consequently 
the  success  of  the  operation,  and  it  was  assuredly  this  which  pre- 


RUPTURE  OF  THE  PERINEUM. 


223 


vented  the  success  of  the  operation  for  perineal  suture,  performed 
in  1 S32,  by  Dr.  Guersent,  jiui. 

The  operation  for  reunion  of  a laceration  of  the  perineum  consists, 
then,  simply  in  first  freshening  the  cicatrized  surfaces  with  a bistoury 
or  with  curved  scissors,  as  was  done  successfully,  ten  years  since,  by 
Doctor  Emile  Barthelemi  ;*  and  then  bringing  the  parts  together 
with  great  accuracy  by  means  of  points  of  suture.  The  first  should 
be  placed  towards  the  anus,  the  second  near  the  vulva,  and  the 
others  between  these  two.  We  may  add,  that  in  general,  three  su- 
tures are  sufficient,  and  that  the  time  chosen  for  the  operation  should 
be  as  distant  as  possible  from  the  menstruation  ; and  that,  following 
the  example  of  M.  Roux,  the  precaution  should  be  observed  of  pre- 
paring the  female  for  the  operation,  by  restricting  her  for  eight  days 
before,  to  a strict  diet  and  the  use  of  diluents.  It  is  also  very  im- 
portant after  the  operation,  to  keep  the  bowels  soluble  and  to  main- 
tain even  a slight  diarrhoea  ; for  the  effects  caused  by  the  expulsion 
of  hardened  faecal  matter  have  often  led  to  failure  of  the  operation, 
by  causing  laceration  of  the  points  of  suture  and  of  the  incipient 
union. 

From  the  operation  not  being  performed  for  a long  time  after  the 
occurrence  of  the  accident,  should  the  skin  be  too  rigid  to  allow  of 
the  approximation  of  the  parts,  we  ought,  in  M.  Dieftenbach?s  man- 
ner, to  make  a deep  incision  to  the  right  and  left,  so  as  to  permit 
the  surfaces  to  be  brought  into  contact  without  stretching,  though  this 
may  have  seemed  before  quite,  impossible.  Finally,  if  there  be  no 
chance  whatever,  by  means  of  a surgical  operation,  we  should  seek 
to  afford  some  relief  to  the  patient  by  means  of  a plug  placed  in  the 
vagina,  or  by  some  apparatus  devised  according  to  the  circumstances 
of  the  case,  and  maintained  by  an  appropriate  bandage. 

[The  lacerations  of  the  perineum  are  sometimes,  when  uncured,  disastrous 
for  the  future  peace  and  happiness  of  the  sufferer:  yet  it  is  not  so  with 
every  one,  as  I can  testify  from  my  knowledge  of  a case  which  I shall 
relate. 

Many  years  ago,  a lady  here  was  delivered  of  her  first  child,  with  forceps, 
under  the  care  of  a distinguished  practitioner,  and  suffered  a frightful  lacera- 
tion of  the  perineum,  from  the  effects  of  which  she  recovered  her  health 
after  long  and  severe  sufferings.  She  subsequently  gave  birth  to  two  chil- 
dren, under  the  management  of  the  same  gentleman  ; after  which  I attended 
her  in  all  her  subsequent  confinements,  amounting  to  four. 

Knowing  nothing  of  the  peculiar  nature  of  her  situation,  as  she  was  in  active 
labour,  I Touched  the  child  soon  after  arriving,  and  discovered  nothing  extra- 
ordinary. Sometime  later,  as  the  waters  had  gone  off,  I Touched  again,  and 
was  shocked  to  find  that  there  were  faeces  in  the  vagina,  which,  at  first,  I 
felt  disposed  to  assign  to  a recto-vaginal  rupture,  which  might  have  occurred, 
as  I supposed,  during  some  one  of  the  violent  throes  that  she  was  experi- 

* La  Lancette  Fran^aise,  t.  vi.  n.  102,  p.  4!  8. 


224 


RUPTURE  OF  THE  VAGINA. 


encing.  The  child  was  born,  however ; and,  after  the  delivery  of  the  placenta, 
I carefully  examined  the  vagina.  I*now  learned  that  what  I had  supposed  to 
be  a regularly  formed  vulva  and  vagina  consisted  of  an  opening  extending 
from  the  posterior  half  of  the  anus  to  the  anterior  commissure  of  the  vulva, 
or,  what  might  very  properly  be  called  a cloaca;  for  the  anterior  perineum 
had  wholly  disappeared,  and,  along  with  it,  all  the  anterior  semicircumference 
of  the  lower  part  of  the  rectum,  whose  anterior  margin  I felt  up  within  the 
cloaca,  and  lying  near  the  sacrum.  Under  such  circumstances,  of  loss  of 
substance  and  structure,  had  she  now  borne  three  children,  and  has  had 
three  others  since  that  time.  I am  assured  by  her  that,  except  when  she 
labours  under  some  diarrhoea  or  looseness  of  the  bowels,  she  has  not  the 
least  trouble  on  account  of  this  new  stale  of  the  parts  ; discharging  her  faeces 
at  regular  and  stated  times,  and  with  the  same  facility  as  a person  in  health 
might  enjoy.  Moreover,  her  health  is  good. 

I take  pleasure  in  stating  this  case,  since  it  may  enable  ns  to  offer  some 
hope  and  encouragement  to  others  who  may  chance  to  be  affected  in  a simi- 
lar manner. — M.] 

OF  LACERATIONS  AND  OF  RUPTURE  OF  THE  VAGINA. 

The  vagina,  as  we  shall  see  presently,  is  exposed  not  only  to  rup- 
ture during  labour,  but  the  walls  of  the  canal  are,  moreover,  subject 
to  lacerations  or  perforations  produced  by  wounding  bodies  or  by 
external  violence.  Plazoni*  cites  the  case  of  a young  woman  whose 
recto-vaginal  septum  was  perforated  by  the  violent  efforts  of  a first 
copulation.  Diemerbroeckt  also  mentions  two  young  Dutch  women 
who  not  only  experienced  the  same  accident,  but  who  actually  per- 
ished of  haemorrhage  the  first  night  of  their  marriage.  Lacerations, 
not  less  considerable,  have  often  been  produced  without  haemor- 
rhage, by  wounding  bodies  still  more  capable  of  determining  dan- 
gerous consequences.  We  attended  a young  girl,  aged  seventeen 
years,  who,  while  balancing  herself  with  one  of  her  friends  on  the 
trunk  of  a tree,  had  both  the  vagina  and  the  has  fond  of  the  -blad- 
der perforated  by  a sharp  splinter  of  wood  upon  which  she  suddenly 
fell.  The  laceration,  which  was  triangular,  and  was  more  than 
six  lines  of  diameter,  produced  scarcely  any  flow  of  blood.  We 
passed  a catheter  into  the  bladder,  and  left  it  there  to  give  issue  to 
the  urine  and  prevent  it  from  impeding  the  cicatrization  of  the 
wound.  The  inflammatory  symptoms  we  afterwards  combated  by 
means  of  prolonged  baths,  by  bleeding,  by  the  application  of  leeches 
to  the  hypogastrium,  rigorous  diet,  etc.  Five  weeks  after  the  acci- 
dent, the  cure  was  complete.  The  Lancetle  Frangaise  published, 
not  long  since,  the  case  of  a young  girl,  in  the  environs  of  Bordeaux, 
who,  while  playing  on  a hay-rick,  had  the  recto-vaginal  septum 
perforated  by  the  point  of  a pitchfork.  Although  the  injury  result- 
ing from  this  accident  was  very  great,  there  was  scarcely  any  hsemor- 

* De  Part.  Generat.  Inservientibus,  lib.  ii.  cap.  xiv.  p.  164. 

f Anat.  Corporis  Humani,  lib.  x.  cap.  36. 


RUPTURE  OF  THE  VAGINA. 


225 


any  haemorrhage,  and  the  patient,  under  a rational  treatment,  soon 
recovered.  Finally,  we  are  about  to  give  another  example  still 
more  remarkable,  which  is  very  analogous  to  the  one  just  mentioned, 
and  is  to  be  found  in  the  fifty-sixth  volume  of  the  Dictionnaire  des 
Sciences  Medicates , p.  461.  A girl,  twenty  years  old,  sliding  down 
a haycock,  fell  upon  a sharp  stick  of  wood,  that  was  armed  with  a 
lateral  hook,  the  handle  placed  against  the  ground.  The  stick  was 
an  inch  in  diameter,  the  point  obtuse,  the  hook  sharp  and  crooked: 
there  was  an  interval  of  five  inches  and  a half  between  its  point  and 
that  of  the  stick,  and  a distance  of  eighteen  lines  between  the  point 
and  the  stick  itself,  without  counting  the  thickness  of  the  latter.  All 
this  part  of  the  instrument  penetrated  within  the  vulva;  and  when 
the  first  attempts  at  extraction  were  made,  the  hook,  which  had 
penetrated  the  abdomen  through  the  posterior  wall  of  the  vagina, 
became  fixed  between  that  canal  and  the  rectum.  After  frequent 
attempts  made  by  another  physician,  Dr.  Rey  succeeded  in  extracting 
the  foreign  body  without  incision  and  without  much  violence.  He 
commenced  by  disengaging  the  point  of  the  hook  by  turning  it 
towards  the  pubis,  while,  at  the  same  time,  he  strongly  depressed 
the  wound  in  the  vagina.  The  extraction  was  then  instantly  accom- 
plished. A consecutive  peritonitis  was  quelled,  and  the  cicatriza- 
tion was  completed  in  seven  weeks. 

Though  such  lacerations  and  accidents  as  the  above  are  not  always 
mortal,  nor  even  followed  by  haemorrhage,  it  sometimes  happens  that 
solutions  of  continuity  of  the  vagina,  of  little  depth,  and  even  simple 
excoriations  or  slight  cuts  of  the  lining  membrane  of  this  canal,  have 
produced  dangerous  losses  of  blood,  and  even  death  itself.  Accidents 
of  this  kind  occur  particularly  when  the  vaginal  mucous  membrane 
has  become  the  seat  of  a varicose  disorder,  which  renders  it  less 
resisting,  and  augments,  at  the  same  time,  the  danger  of  the  wounds. 
These  varices  of  the  vagina,  which  often  burst  during  labour,  some- 
times give  rise  to  effusions  of  blood,  which,  involving  the  pelvic 
cellular  tissue,  and  especially  the  lips  of  the  vulva,  occasion  the  most 
frightful  accidents,  and  those  dangerous  and  often  fatal  thrombuses  of 
the  vulva  to  which  Professor  Boer,*  Madame  Lachapelle,t  and  espe- 
cially M.  Deneux,f  have  directed  the  attention  of  the  profession. 

The  indication  presented  by  thrombus  of  the  vulva,  is  the  follow- 
ing : to  give  issue  to  the  accumulated  blood  by  means  of  an  incision 
made  from  without ; and  to  procure  the  approximation  of  the  edges 
of  the  cavity  by  plugging  up  the  vagina,  in  such  a way,  however,  as 
to  leave  a free  passage  to  the  uterine  fluids,  by  means  of  a large 
canula. 

Lacerations  of  the  vagina,  effected  during  labour,  may  take  place 
either  in  the  superior  portion  of  the  canal,  that  is  to  say,  towards 
the  point  where  it  unites  with  the  neck  of  the  uterus,  or  in  its 
middle  and  inferior  portion.  This  kind  of  rupture  is  always  the 
effect  of  extreme  distension,  produced  by  the  head  of  the  child,  or 

* Mat.  Med.  Obs.,  lib.  vii.  p.  24. 

f Pratiq.  des  Accouch.  ou  Mem.  et  observ.  choisies,  etc.,  t.  iii.  pp.  130.  197.  199. 

t Memoire  sur  les  Tumeurs  Sanguines  de  la  Vulve  et  du  Vagin.,  1830. 

15 


226 


RUPTURE  OF  THE  VAGINA. 


the  result  of  the  direct  action  of  the  hand  or  of  obstetrical  instru- 
ments. Laceration  of  the  upper  extremity  of  the  vagina,  which  is 
the  most  frequent  of  all,  has  often  been  mistaken  for  rupture  of  the 
uterus  itself.  It  is  true,  ihat  laceration  of  one  of  these  organs  some- 
times extends  to  the  other,  whichever  be  the  one  in  which  it  com- 
menced. When  the  rupture  of  the  vagina  has  occurred  above,  the 
canal  seems  simply  to  have  broken  its  connection  with  the  cervix 
uteri;  for  division  of  the  superior  portion  assumes  almost  always 
a transverse  direction,  which  is  not  the  case  when  the  laceration  takes 
place  upon  any  other  point. 

A rupture  of  the  middle  portion  of  the  vagina  often  extends  to  the 
perineum,  and  is  merely  a continuation  of  the  laceration  of  this  infe- 
rior paries  of  the  pelvis.  It  is  useless  for  us  to  dilate  at  this  point 
upon  the  symptoms  of  these  lacerations,  as  they  bear  the  strongest 
analogy  to  those  of  the  uterus,  of  which  we  shall  soon  treat;  it  is 
sufficient  to  say,  that  the  prognosis  is  usually  more  favourable  than 
for  laceration  of  the  womb,  and  that  the  patients  have  soon  been  re- 
stored, even  in  cases  where  the  intestines  had  passed  into  the  vagina, 
and  in  others,  when  the  child  had  escaped  into  the  cavity  of  the 
abdomen.  The  extraction  of  the  foetus  and  placenta,  which  is  the 
most  important  indication,  is  always  effected  without  much  difficulty 
through  the  accidental  perforation  of  the  vagina,  the  edges  of  which 
do  not  contract  like  those  of  the  uterus ; so  that  an  attentive  and 
dexterous  practitioner  may  often  accomplish  a perfect  delivery 
without  employing  violence,  and  thus  remove  the  principal  obstacles 
to  cicatrization.  We  should  not  omit  to  state  that  what  especially 
distinguishes  rupture  of  the  vagina  from  that  of  the  uterus,  is  that 
vaginal  lacerations  preserve  the  same  extent  and  breadth  after  the 
termination  of  the  labour,  while  uterine  lacerations  lose  in  diame- 
ter in  proportion  as  the  gestative  organs  become  contracted.  In 
some  very  rare  cases  a double  rupture  of  the  vagina  takes  place, 
that  is  to  say,  the  laceration  extends  into  the  walls  both  of  the  bladder 
and  of  the  rectum.  Professor  Chaussier  exhibited  to  the  Society  of 
Medicine  of  Paris,  a specimen,  which  presented  a double  rupture 
occupying  both  the  anterior  and  posterior  walls  of  the  vagina.  This 
specimen  was  taken  from  a female  who  had  been  the  victim  of  ill- 
directed  manipulations  during  her  labour. 

If  laceration  of  the  vagina  be  less  dangerous  than  that  of  the 
uterus,  it  is  because  of  the  greater  facility  of  extracting  the  child, 
and  because  of  the  small  quantity  of  blood  which  escapes  after  the 
accident.* 

* Veslingius,  however,  remarks  that  he  has  twice  seen  rupture  of  the  vagina  fol- 
lowed by  mortal  haemorrhage.  Bis  enim  notavi,  cum  uteri  vagina  secundum  latus 
dextrum  esset  disrupta , quamvis  foetus  extinctus  intcgre  cum  secundinis  educeretur,  sub- 
sequente  ex  laceratis  hypogastricis  vasis  cnormi  sanguinis  projluvio,  matrem  paulo  post 
pariterfalo  cccisse.  It  is  probable  that  in  these  two  cases,  and  in  most  others  of  the 
same  kind,  the  vaginal  mucous  membrane  was  the  seat  of  a varicose  condition, 
which  had  facilitated  the  rupture  and  determined  the  haemorrhage. 


CONTUSION  AND  WOUNDS  OF  THE  UTERUS. 


227 


OF  CONTUSIONS  AND  WOUNDS  OF  THE  UTERUS. 

When  empty,  the  uterus  being  movable  and  concealed  in  the  pel- 
vic cavity,  is  very  rarely  injured  by  external  violence  or  wounding 
bodies. 

While  operations  performed  upon  the  neck  of  this  organ,  and  lace- 
rations produced  by  the  ignorance  of  obstetricians,  and  by  the  head 
of  the  foetus,  prove  that  wounds  of  this  part  are  not  usually  dan- 
gerous, it  is  not  so  in  regard  to  those  seated  in  the  body  of  the  womb. 
Nevertheless,  wounds  of  the  body  of  this  viscus  are  not  always 
necessarily  mortal ; for  instances  of  recovery  are  on  record,  not  only 
after  the  Caesarian  operation,  but  even  after  the  rupture  of  the  organ, 
or  after  wounds  which  seemed  really  to  leave  no  hope.  Reichard,* 
in  his  excellent  dissertation,  reports  the  case  of  a woman  pregnant 
and  at  term,  who  received  several  wounds  from  a gvn  loaded  with 
small  balls,  one  of  which  struck  her  in  the  left  side  of  the  hypogas- 
trium.  This  wound,  in  particular,  gave  rise  to  an  abundant  haemor- 
rhage, which  was  soon  followed  by  syncope,  but  labour  having  come 
on,  and  delivery  taken  place  spontaneously,  it  was  discovered  that 
the  child  had  been  struck  under  the  right  clavicle,  and  that  there  was 
a wound  in  which  was  found  one  of  the  balls  and  a portion  of  the 
mother’s  clothing.  Notwithstanding  this,  both  of  them  recovered, 
but  the  wound  of  the  mother  remaining  fistulous,  was,  for  a long 
time,  the  seat  of  a purulent  discharge,  and  what  is  more  extraor- 
dinary, gave  issue  to  the  menstrual  fluid  ; this  wound,  which  did  not 
close  until  three  years  after,  would  have  done  so  much  sooner  had 
it  not  been  dilated  by  a canula,  which  it  was  thought  proper  con- 
stantly to  retain  in  it.  The  same  author  cites  other  examples  of 
wounds  of  the  uterus,  from  Langius  and  Hoffman,  which  were  fol- 
lowed by  very  rapid  recovery.  In  one  of  the  cases  the  wound  was 
made  by-  a knife,  which  had  opened  the  cranium  of  the  child ; in 
another,  it  was  produced  by  a blow  from  a pointed  stick,  which 
had  injured  the  thorax  of  the  infant ; finally,  in  a third  case,  which 
we  regard  as  impossible  or  as  incorrectly  reported,  there  is  mention  of 
a woman  whose  ute/ine  and  abdominal  parietes  were  so  extensively 
lacerated  by  a bulks  horn,  that  the  foetus  enclosed  in  its  membranes 
escaped  through  the  wound  and  fell  upon  the  ground.  The  child 
having  been  replaced  in  the  womb,  and  the  parietes  of  the  abdo- 
men closed  by  means  of  a suture,  the  women  recovered  perfectly, 
and  gave  birth,  at  the  usual  period,  to  a healthy  girl.  M.  Deneux,t 
and  Dessaitlt,f  report  from  Sue,  Schmucker,  and  other  authors,  au- 
thentic facts  nearly  similar  and  followed  by  entire  recovery,  but  in 
these  cases,  the  child  had  escaped,  or  had  been  instantly  extracted 
through  the  open  wound  of  the  abdomen  and  uterus.  Roussel§  like- 
wise cites  the  instance  of  a female  who  recovered  perfectly  of  a wound 
produced  by  a musket  ball,  which,  traversing  the  abdomen  and 

* Dissert,  exhib.  uterum  gravide  una  cum  foetu  vulneratum. 

f Essai  sur  la  Rupt.  de  la  Matrice,  etc.,  p.  24. 

4 Journal  de  Chirurgie,  t.  ii. 

§ Traite  nouv.  de  l’Hysteromotokie  ou  enfant,  Cesar.,  p.  120. 


228 


CONTUSIONS  AND  WOUNDS  OF  THE  UTERUS. 


parietes  of  the  womb,  had  destroyed  the  child  In  the  History  of  the 
Academy  of  Sciences,  (for  the  year  1709,  p.  22,)  mention  is  made 
of  a washerwoman  who,  at  the  sixth  month  of  gestation,  was 
wounded  in  the  uterus  by  a pointed  stake  of  a palisade.  After  the 
occurrence  of  the  accident,  a good  deal  of  blood  and  then  pus 
escaped  by  the  vagina ; several  abscesses  formed  afterwards  : finally, 
after  opening  a considerable  tumour,  whence  escaped  the  remains 
of  the  foetus,  perfect  recovery  took  place  shortly  afterwards.  Do  we 
not  know,  moreover,  that  the  operation  of  tapping  was  performed 
successfully  in  a woman  aged  fifty-three  years,  whose  uterus  was 
distended  by  an  enormous  quantity  of  serous  fluid,*  and  that,  in  an- 
other case,  the  womb  of  a pregnant  and  dropsical  female  was  acci- 
dentally pierced  by  a trocar  ? Doctor  Simmonst  states  that  the  acci- 
dent was  recognized  by  a discharge  of  blood  and  the  acute  pain 
which  followed  the  puncture,  and  adds  that,  notwithstanding  this 
wound  of  the  uterus,  the  gestation  went  on  regularly  to  term. 

Although  the  facts  that  we  have  just  mentioned  seem  to  show  that 
the  prognosis  of  wounds  of  the  uterus  is  not  so  grave  as  one  might 
at  first  suppose,  there  is  a much  greater  number  of  cases  on  record 
where  death  has  been  the  immediate  consequence  of  wounds,  even 
slight  ones,  of  the  parietes  of  this  organ.  In  order  not  to  dilate  too 
much  on  this  subject,  we  shall  content  ourselves  by  quoting  some  of 
these  examples.  Brendeliusf  records  the  case  of  a young  girl,  who, 
wishing  to  procure  abortion,  had  several  times  plunged  a sharp  instru- 
ment through  the  walls  of  the  neck  of  the  uterus,  which  perforated 
the  membranes  and  destroyed  the  child.  This  criminal  act  was  fol- 
lowed by  a considerable  haemorrhage,  then  by  delirium,  convulsions 
and^death.  Devaux§  states,  that  he  was  called,  on  the  8th  March, 
1695,  to  Jane  Berthot,  pregnant  at  eight  months,  who  had  just  been 
wounded  by  a sword  in  the  hypogastrium,  at  the  distance  of  three 
finger-breadths  from  the  umbilicus ; this  woman  was  dead  before  any 
dressing  could  be  applied : the  autopsy  showed  that  the  sword, 
after  having  passed  through  the  uterus  near  its  fundus,  had  taken 
effect  in  the  thorax  of  the  child,  and  occasioned  a large  effusion 
of  blood,  which  explained  the  sudden  death  of  ^he  mother  and  child. 
Planchon||  also  speaks  of  a woman  pregnant  at  seven  months,  whose 
abdominal  parietes  were  pierced  by  a large  nail  three  inches  from 
the  umbilicus ; this  wound,  which  at  first  occasioned  little  pain,  was 
followed  by  an  abundant  discharge  of  blood,  mixed  with  water ; 
the  abdomen  soon  collapsed  and  the  uterus  contracted  •,  on  the  fol- 
lowing day  convulsions  came  on ; there  was  frequent  singultus, 
bilious  vomiting,  and  death,  which  occurred  sixty  hours  after  the 
accident.  Upon  the  examination  of  the  body,  it  was  found  that  the 
foetus  had  been  slightly  wounded  in  the  right  shoulder,  and  that  the 

* Wirer  Annales  de  Lit.  M£d.  etrangere,  p.  190. 

f Idem.  tom.  ii.  p.  460. 

i Ephemerides  Natur.  cur  observat.  147,  centur.  iii.  et  iv. 

§ L’Art  de  faire  des  Rapports  en  Chirurg.,  p.  176  et  177. 

U Traite  de  l’Operat.  CLsar.  (loc.  cir.) 


CONTUSIONS  AND  WOUNDS  OP  THE  UTERUS. 


229 


puncture  in  the  uterus  was  very  small,  and  situated  two  inches 
lower  down  than  that  in  the  abdominal  parietes. 

Wounds  of  the  uterus,  during  pregnancy,  are  therefore  in  general 
very  dangerous,  not  only  because  of  the  augmented  sensibility  and 
great  dilatation  of  the  vessels  of  that  organ,  but  also  because  they 
most  commonly  bring  on  abortion,  give  rise  to  haemorrhage,  and 
especially  to  sanguine  extravasations,  which  it  is  as  difficult  to  guard 
against  as  to  arrest. 

Wounds  of  the  gestative  organ  are  detected  by  the  situation  of  the 
external  wound,  by  the  direction  of  the  wounding  body,  by  the 
pain  felt  in  the  hypogastric  region,  in  the  groins,  loins,  thighs;  by  the 
uterine  haemorrhage,  the  distension  of  the  abdomen  produced  by  the 
effusion  of  blood,  and  the  other  symptoms  common  in  wounds  of  the 
abdominal  viscera.  In  cases  of  this  kind,  recourse  should  be  had, 
without  delay,  to  the  most  powerful  antiphlogistics,  such  as  repeated 
general  bleedings,  the  application  of  leeches,  of  emollient  fomenta- 
tions, the  use  of  demulcent,  narcotic  and  camphorated  enemata,  of 
small  bulk,  so  as  to  be  retained  ; finally,  mucilaginous,  astringent  and 
antispasmodic  drinks,  and  a number  of  other  remedies,  which  should 
he  modified  according  to  the  case  and  the  symptoms. 

Traumatic  uterine  haemorrhage  presents  but  little  danger  in  the 
non-gravid  state  ; it  is  arrested  without  much  difficulty,  by  repose 
and  the  use  of  cold  and  astringent  drinks.  Should  the  flow  of  blood 
be  obstinate,  and  especially  if  the  patient  be  already  prostrated,  we 
should  have  recourse  to  a much  more  active  medication ; for  exam- 
ple, we  might  prescribe  a cold  solution  of  sulphate  of  alumina,  to  be 
used  as  a drink,  as  an  injection  into  the  vagina,  and  as  a topical  appli- 
cation to  the-  exterior  orifice  of  the  wound,  by  means  of  linen  wet 
with  it.  We  might,  with  advantage,  substitute  for  the  internal  use 
of  the  alum  a solution  of  extract  of  rhatany,  (two  drachms  to  the 
pint  of  water,)  sweetened  with  syrup  of  comfrey  root.*  This  astring- 
ent substance  seems  to  exert  a special  influence  upon  the  uterus,  and 
to  be  more  efficacious  than  any  other  remedy  of  the  same  kind  in 
arresting  haemorrhage  from  the  organ.  It  would  be  equally  well  to 
prescribe  the  extract  of  rhatany  in  enemata,  and  with  addition  of 
two  grains  of  camphor,  or  assafostida,  and  ten  drops  of  tincture  of 
castor,  if  the  haemorrhage  were  accompanied  by  hiccough  and  other 
nervous  symptoms.  Traumatic  uterine  haemorrhages  are  generally 
difficult  to  arrest  during  pregnancy  ; unfortunately,  all  the  remedies 
we  can  propose  often  fail,  and  the  bleeding  ceases  most  frequently 
only  after  delivery,  of  which,  therefore,  we  must  try  to  hasten  the 
termination. 

CONTUSIONS  AND  WOUNDS  OF  THE  MAMM2E. 

Though  the  mammae  are  very  much  exposed  by  their  situation  to 

* The  following  mixture,  taken  in  tablespoonful  doses  every  quarter  of  an  hour,  has 
been  followed  by  good  results,  whenever  we  have  used  it,  in  cases  of  uterine  haemor- 
rhage, which  other  means  had  failed  to  arrest. 

R. — Infusion  of  orange  leaves,  3 viij ; extract  of  rhatany,  3 ij ; syrup  of  comfrey  root, 
^i. ; syrup  of  poppy-heads,  3i. ; sulphuric  ether,  Ti|x. 


230 


CONTUSIONS  AND  WOUNDS  OF  THE  MAMMAS. 


the  contact  of  external  bodies,  and  consequently  to  various  contusions, 
it  is  uncommon  for  them  to  be  wounded  by  pricking  or  cutting  in- 
struments, unless  in  some  surgical  operation. 

Contusions  of  the  breasts,  however  slight,  are  always  painful ; 
yet  they  are  rarely  followed  by  ecchymosis ; and  though  they  occa- 
sion only  mild  symptoms  at  first,  often  produce,  after  several  days, 
swellings,  induration  and  engorgements,  which  deserve  the  more  to 
fix  the  attention  of  physicians,  because  they  are  the  most  frequent 
cause  of  cancer  of  the  mammae. 

When  contusions  or  wounds  of  the  mammae  have  occurred  during 
the  menstrual  flow,  it  often  happens  that  that  discharge  is  modified, 
that  is  to  say,  suppressed,  diminished,  or  increased.  During  gestation 
and  lactation,  these  contusions  of  the  mammae  produce  more  serious 
consequences.  In  the  former  case,  the  breasts  being  more  highly 
endowed  with  sensibility,  become  the  seat  of  more  considerable  in- 
flammation and  engorgement ; in  the  latter,  there  is  conjoined  to  these 
symptoms,  diminution  of  the  secretion  of  milk,  and  often  complete 
suppression  of  the  secretion. 

The  consequences  of  blows  received  upon  the  mammae  are  more 
or  less  grave,  in  proportion  as  the  pain  they  produce  is  superficial 
or  deep  seated.  When  the  pain  is  superficial,  the  subcutaneous  cellu- 
lar tissue  is  generally  alone  affected  ; in  the  contrary  case,  the  mam- 
mary gland  is  the  seat  of  the  pain,  and  the  prognosis  becomes  still 
more  unfavourable  if  the  patient  have  arrived  at  her  critical  period. 

Contusions  of  the  breasts  then  merit  the  greater  attention,  because 
of  the  unfortunate  consequences  which  sometimes  result  from  them : 
we  should  therefore  resort  to  the  employment  of  antiphlogistics, 
such  as  general  bleedings,  the  application  of  leeches  around  the  part 
contused,  discutients,  if  there  be  ecchymosis,  cataplasms  of  flax-seed 
meal  sprinkled  with  laudanum;  and,  indeed,  we  should  persevere 
with  all  these  remedies  until  the  pain  and  all  traces  of  inflammation 
have  disappeared. 

Wounds  of  the  breasts,  produced  by  puncturing  instruments,  such 
as  a nail,  a needle,  etc.,  require,  in  the  same  way,  the  employment  of 
general  and  local  bleedings,  and  of  discutient,  emollient,  and  narcotic 
applications,  according  to  the  nature  of  the  wound  and  the  symptoms. 
During  pregnancy  we  should  prefer  bleeding  from  the  arm  to  the 
local  use  of  leeches,  unless  important  circumstances  contra-indicate 
it.  If  the  woman  be  suckling  we  ought  to  dispense  with  the  use  of 
sanguine  evacuations,  excepting  in  cases  where  the  breasts  are  much 
engorged  or  when  there  is  suppression  of  the  milk. 

When  the  contusion  or  wound  of  the  mammae  has  produced  a dis- 
tinct diminution  or  suppression  of  the  menstruse,  we  should  endea- 
vour to  recall  this  discharge,  or  substitute  for  it  an  application  of 
leeches  to  the  vulva,  or  to  the  superior  and  inferior  portion  of  the 
thighs. 


OF  RUPTURE  OF  THE  UTERUS. 

Rupture  of  the  uterus  is  a solution  of  continuity  of  the  parietes 


RUPTURE  OF  THE  UTERUS. 


231 


of  this  organ  occurring  spontaneously  during  pregnancy,  and  most 
generally  during  labour,  or  caused  by  wounds  or  violence  exerted 
upon  the  hypogastric  region.  In  some  cases  the  external  agents 
open  the  abdominal  parietes,  and  act  directly  upon  the  gestative 
organ.  Rupture  of  the  womb  has  several  times  been  seen  to  be  the 
result  of  a wound  of  this  viscus  by  the  horn  of  a furious  bull  ;* 
the  same  accident  has  followed  a wound  produced  by  the  fragment 
of  a glass  chamber-pot,  upon  which  the  woman  was  seated ; it  has 
followed  a gun-shot  wound,  a blow  with  a sabre  or  a bayonet, 
and  has  been  caused  by  the  iron  ferule  on  the  end  of  a gig  shaft,! 
and  finally  by  other  wounding  bodies  which  it  is  useless  to  indicate. 
Accidental  rupture  of  the  uterus  takes  place  also  in  cases  where  the 
parietes  of  the  abdomen  have  remained  uninjured,  in  consequence 
of  strong  pressure,  distending  the  uterine  fibres  to  a greater  degree 
than  comports  with  the  ductility  and  extensibility  of  which  they 
are  susceptible. 

The  records  of  science  contain  the  case  of  a female  whose  uterus 
was  ruptured  in  consequence  of  violent  compression  of  the  abdo- 
men, between  a carriage  and  a wall;!  in  another  person,  the  same 
accident  took  place  from  her  being  kicked  by  an  unruly  horse,  and 
thrown  on  a sharp  stone  which  struck  against  the  umbilical  region  :§ 
finally,  in  a third,  the  rupture  was  the  unfortunate  result  of  a severe 
fall  upon  the  abdomen.  In  the  greater  part  of  the  cases  which  we 
have  just  reported,  the  child  passed  wholly  or  partially  into  the 
cavity  of  the  peritoneum ; but  the  rupture  did  not  occur  immediately 
after  the  accidents  which  were  the  cause  of  it.  The  too  great  ex- 
tension of  the  fibres  of  the  uterus,  and  their  weakness,  determined 
by  contusions  or  wounds,  although  not  involving,  in  all  cases,  the 
whole  thickness  of  the  parietes  of  the  organ,  probably  facilitated 
the  subsequent  complete  laceration,  either  by  the  power  of  a uterine 
contraction,  or  some  other  effort,  or  by  the  giving  way  of  the  eschar 
of  the  contused  parts,  which  had  mortified.  There  is  yet  another 
rather  frequent  cause  of  rupture  of  the  uterus,  the  forcible  introduc- 
tion of  the  hand  into  the  cavity  of  the  organ,  and,  still  more,  of  for- 
ceps and  certain  instruments,  which  act  as  puncturing  or  cutting 
instruments,  producing  real  wounds,  or  causing  pressure  or  tractions 
which  lacerate  the  fibres  of  the  organ.  We  ought,  however,  to 
confess  that,  in  a great  number  of  cases,  it  is  very  difficult,  and  even 
impossible,  to  ascertain  whether  the  rupture  has  taken  place  sponta- 
neously, or  whether  it  has  been  produced  by  the  imprudent  mani- 
pulations of  the  accoucheur,  or  by  some  extrinsic  influence.  The 
following  case,  reported  by  Professor  Desormeaux,  on  the  authority 
of  Dr.  Moulin,  shows  the  obscurity  which  prevails  on  this  pdint:  — 
In  a woman  who  was  suffering  the  most  violent  parturient  pains, 
the  uterus  presented  a very  marked  anterior  obliquity.  The  mid- 
wife, who  had  vainly  endeavoured  to  restore  the  organ  to  its  natural 

* Sue,  Essai  histor.  sur  l’art  des  accouch.,  t.  i.  p.  209.  Deneux,  from  Lechaptois : 
Essai  sur  les  Rupt.de  la  Matr.,  p.  35. 

| Planchon.  Traite  de  I’Operat.  Cesar.,  p.  77. 

$ Ancien.  Journal  de  Medecine,  t.  liv.  p.534  et  672. 

§ Mauritaneus  Cordseus.  Hist,  de  l’Acad.  des  Sciences,  1709. 


332 


RUPTURE  OF  THE  UTERUS. 


direction,  wishing  to  renew  her  attempts,  took  advantage  of  a pow- 
erful uterine  contraction,  to  introduce  a finger  into  the  vagina;  but 
scarcely  had  this  introduction  commenced,  when  the  woman  cried 
out  that  they  were  tearing  her  insides.  Symptoms  ensued,  which 
made  it  necessary  to  transfer  the  patient  to  the  Hotel-Dieu,  where  a 
rupture  of  the  inferior  portion  of  the  uterus  was  discovered,  which 
was  soon  followed  by  death. 

The  predisposing  causes  of  the  affection  which  now  occupies  our 
attention  are,  excessive  irritability  of  the  uterus;  weakness  or  too  great 
rigidity  of  its  tissue ; a scirrhous  condition  of  the  cervix  ; occlusion  of 
its  orifice  ; contracted  pelvis ; osseous  or  fibrous  tumours  in  that  cavi- 
ty ; obliteration  of  the  vagina,  and  incomplete  atresia  of  the  vulva ; 
scirrhous  tumours  of  the  ovary  ; faulty  position  of  the  foetus,  and  all 
the  causes  that  act  as  obstacles  to  delivery  and  render  the  expulsive 
efforts  vain:  finally,  there  have  been  reckoned  amongst  the  pre- 
disposing causes  of  rupture  of  the  uterus,  undue  distension  and  thin- 
ning of  that  portion  of  the  viscus  which'  corresponds  to  the  insertion 
of  the  Fallopian  tubes,  unequal  thickness  of  the  parietes  of  the  same 
organ,  and,  lastly,  weakness  of  its  tissue,  whether  resulting  from  an 
ancient  cicatrix,  from  a wound,  from  an  antecedent  suppuration,  from 
the  presence  of  a fibrous  tumour,*  or  from  any  cause  whatever. 
According  to  Denman,  pressure  and  attrition  between  the  child’s 
head  and  projecting  points  'of  bone  in  badly-formed  pelves,  may 
wear  away,  mechanically,  the  walls  of  the  uterus.  When  any  of  the 
predisposing  causes  we  have  just  indicated  exist,  rupture  may  be 
produced  by  the  sudden  contractions  and  more  or  less  violent  efforts 
which  result  from  coughing,  sneezing,  vomiting,  or  from  lifting  a 
heavy  burden.  The  same  accident  may  occur  from  violent  anger, 
or  sudden  fright.  M.  Duparque  has  published  several  cases,  which 
leave  no  doubt  on  this  point. 

The  determining  causes  of  spontaneous  rupture  of  the  uterus  are 
very  difficult  to  ascertain.  Some  authors,  as  Delamotte,  Levret, 
Deventer,  Crants,  and  M.  Egge,t  regard  the  violent  and  convulsive 
movements  of  the  foetus  as  their  only  cause.  According  to  Roe- 
derer,  this  cause  cannot  be  admitted  ; and  in  this  we  agree  with  him, 
because,  before  the  rupture,  the  child  is  too  strongly  compressed  by 
the  uterine  contractions  to  be  enabled  to  excite  movements  capa- 
ble of  rupturing  the  parietes  of  the  womb;  besides,  the  rupture 
has  often  taken  place  even  where  the  child  had  been  dead  for  seve- 

* Madame  Lachapelle,  Madame  Boivin,  obs.  iii.;  the  Lancette  Frar^aise,  t.  viii.  n. 
126,  p.  389,  quotes  from  an  English  journal,  (the  Edinburgh  Med.  & Kurg.  for  July, 
1833,)  a case  of  rupture  of  the  uterus,  observed  by  Dr.  John  Dunn,  which  took  place 
during  labour,  on  the  15th  April,  1829.  The  laceration  had  occurred  along  the  margin 
of  a large  fibrous  mass.  The  foetus  was  extracted  immediately  through  the  natural 
passages;  and  the  patient,  aged  thirty-seven  years,  recovered  so  entirely,  after  the 
spontaneous  opening  of  an  internal  abscess,  which  discharged  a large  amount  of 
purulent  matter  by  the  anus,  that,  fifteen  months  after  her  cure,  she  was  delivered, 
without  accident,  of  a dead  child,  and,  on  the  27th  October,  she  was  again  safely 
brought  to  bed  of  another  child,  which  was  still  living  on  the  9th  of  February,  1835; 
that  is  to  say,  it  was  aged  nearly  two  years  when  this  interesting  case  was  made 
public. 

f Med.  & Physic.  Journal,  November,  1828. 


RUPTURE  OF  THE  UTERUS. 


233 


ral  days ; and,  as  Planchon  remarks,  no  part  of  the  foetus  had  become 
engaged  in  the  fissure,  which  would  certainly  have  been  the  case, 
had  the  solution  of  continuity  been  produced  by  the  movements  of 
the  infant.  It  seems  more  natural  to  us  to  suppose,  that  spontaneous 
rupture  is  generallycaused  by  a violent  contraction  of  the  uterus, 
which  is,  at  the  same  time,  under  the  influence  of  one  of  the  pre- 
disposing causes  above  cited.  Effectively,  it  has  almost  always 
been  observed,  that  it  is  during  an  energetic  and  convulsive  con- 
traction of  the  uterus  and  of  the  inferior  extremities,  that  uterine 
lacerations  have  taken  place. 

Baudelocque  regards,  as  a very  frequent  and  very  powerful  cause 
of  this  accident,  the  sudden  and  forced  movements  of  the  trunk  dur- 
ing the  uterine  contractions.  In  our  opinion,  this  cause,  if  it  does  not 
produce,  may  at  least  promote  spontaneous  rupture;  and  we  are  the 
more  inclined  to  admit  it,  because  it  acts  at  the  same  time  with  the 
exciting  causes  which  we  have  mentioned. 

Although  ruptures  of  the  uterus  have  generally  taken  place  after 
the  membranes  have  given  way,  and  particularly  when  the  uterine 
contractions  had  reached  their  greatest  degree  of  violence,  it  has 
sometimes  happened  that  they  have  occurred  at  the  beginning  of 
labour,  and  even  during  gestation.  M.  Collineau*  saw  a case  of 
rupture  of  the  womb,  which  occurred  in  the  second  month  of  preg- 
nancy, in  consequence  of  vomiting.  Dr.  Puzint  has  cited  an  example, 
which  was  brought  on  in  the  third  month,  by  an  attempt  to  carry  a 
heavy  burden.  M.  Moulin  £ has  published  another,  which  took  place 
at  the  same  period.  Finally,  M.  Campbell  § and  M.  Duparque||  speak 
of  rupture  of  the  uterus  at  the  fourth  month ; M.  Thomas  Hott,1T  at 
the  sixth,  and  M.  Bochard**  at  the  seventh. 

In  order  to  explain  the  above  cases,  we  are  obliged  to  admit  that 
the  ruptures  were  determined  by  the  organic  causes  mentioned 
above,  or  else  we  must  suppose  them  to  have  occurred  during  semi - 
extra-uterine  pregnancies — that  is  to  say,  those  which  are  seated  in 
an  abnormal  cavity  formed  in  the  substance  of  the  walls  of  the  uterus. 

Authors  have  mentioned,  as  precursory  signs  of  rupture,  tension  of 
the  abdomen,  elevation  of  some  part  of  the  uterus  into  a point,  vio- 
lent movements  of  the  child,  a fixed  and  acute  pain  in  the  same  spot  ; 
again,  strong  pains  without  any  effect,  and  finally,  some  other  phe- 
nomena which  are  far  from  being  always  present,  or  which  exist 
without  the  occurrence  of  rupture : nevertheless,  the  accident  is  to 
be  apprehended  when  there  are  great  obstacles  to  delivery,  and 
especially  where  the  uterine  contractions  are  violent,  prolonged,  and 
accompanied  by  very  severe  pains. 

The  symptoms  showing  that  rupture  has  taken  place,  are  the  fol- 
lowing: the  female,  after  an  energetic  and  convulsive  contraction, 

* Journal  General,  de  Med.,  1808.  -^Dissertation  Inaugurate,  1803. 

* Archives  Generates  de  Medecine,  t.  ix.  p.  132. 

§ The  Lancet,  vol.  i.  p.  31. 

fi  Hist.  Compl.  des  Rupt.  et  de  la  Chirurg.  de  l’Uterus,  p.  42. 

K London  Medical  Repository,  May,  1817. 

**  Journal  de  Med.,  t.  v.  p.  42. 


234 


RUPTURE  OF  THE  UTERUS. 


suddenly  feels  a much  more  intense  pain,  accompanied  by  an  inward 
sensation  of  laceration,  and  by  a peculiar  noise,  or  rather  a sort  of 
tearing  sound,  that  has  sometimes  been  heard  by  the  attendants.  The 
place  where  the  rupture  has  occurred,  then  becomes  the  seat  of  an 
excessively  acute  pain,  like  that  from  a violent  cramp.  The  patient 
litters  a piercing  cry,  her  face  becomes  pale,  her  pulse  grows  feeble, 
she  faints  or  becomes  calmer,  general  coldness  ensues,  and  sometimes 
a gentle  warmth  extends  over  the  whole  of  the  abdomen,  which  sud- 
denly changes  its  form;  the  movements  of  the  foetus  disappear  little 
by  little,  but  the  labour,  which  up  to  this  moment  had  been  too  active, 
is  instantly  suspended ; finally,  in  the  greater  number  of  cases,  death 
follows  a more  or  less  considerable  effusion  of  blood  into  the  abdo- 
men and  from  the  vulva. 

Although  any  portion  of  the  uterine  parietes  may  be  the  seat 
of  laceration,  there  are,  nevertheless,  certain  parts  which  are  more 
liable  to  it  than  others ; for  example,  the  cervix,  the  sides  and  the 
fundus.  If  the  anterior  and  posterior  walls  are  less  subject  to  it,  it 
is  probably  because  they  have  a point  of  support,  one  upon  the 
anterior  paries  of  the  abdomen,  and  the  other  upon  the  vertebral 
column. 

The  foetus  and  its  appendages  do  not  always  escape  from  the 
cavity  of  the  uterus,  after  the  organ  has  been  ruptured  sponta- 
neously, or  from  a wound,  though  it  be  true  that  the  contrary  gene- 
rally happens ; yet  in  some  cases  the  body  of  the  child,  or  only  a part 
of  it,  passes  through  the  rent,  while  the  rest  remains  in  the  uterus, 
even  though  the  placenta  may  have  escaped.*  When  death  does  not 
promptly  follow,  the  laceration  of  the  body  or  fundus  of  the  gestative 
organ  soon  diminishes  in  size,  from  the  contractions  of  the  muscular 
fibres,  and  if  a portion  of  the  foetus  or  placenta,  or  even  a loop  of 
intestine,  should  have  become  engaged  in  it,  they  are  constricted,  and 
strangulated  as  it  were.t  Lacerations  of  the  neck,  on  the  contrary, 
sometimes  remain  open  for  a long  time,  and  allow  of  the  escape  of  a 
considerable  portion  of  intestines  and  epiploon ; finally,  we  deem  it 

* Doctor  Goldson,  in  a pamphlet  published  in  London  in  1787,  has  sought  to  show 
that  the  cases  of  rupture  of  the  uterus,  reported  by  Van  Derwiel,  Douglass,  Bonnet, 
Pouteau,  Manning  and  some  others,  were  really  only  lacerations  of  the  vagina  which 
had  occurred  near  its  insertion  into  the  cervix.  Dr.  Goldson  in  this  way  explains  the 
facility  which  these  observers  met  with  in  the  extraction  of  the  foetus,  which  had 
completely  passed  into  the  abdominal  cavity.  It  is  true  that  the  child  rarely  escapes 
quite  through  a rupture  of  the  womb,  unless  there  be  at  the  same  time  rupture 
of  the  vagina,  because  even  when  the  laceration  is  large  enough,  it  immediately  di- 
minishes, in  consequence  of  the  reduction  produced  by  the  contractions  of  the  organ, 
and  permits  only  of  the  escape  of  a portion  of  the  foetus ; for  example,  the  head  alone, 
(Radford),  or  accompanied  by  an  arm,  (Behling),  or,  finally,  the  two  superior  ex- 
tremities and  the  trunk,  the  feet  remaining  in  the  cavity  of  the  uterus,  as  was  ob- 
served by  Philippe  Peu  (Prat,  des  Accouch.,  p.  79).  Sometimes  the  placenta  has 
been  driven  into  the  abdomen,  while  the  child  has  escaped  only  in  part;  at  other 
times  it  is  expelled  alone  through  the  natural  passages,  while  the  fmlus  is  in  the  ab- 
dominal cavity,  where  it  is  found  by  tracing  the  cord;  finally,  the  membranes  may 
be  retained  in  the  womb,  w’hatever  be  the  position  and  place  occupied  by  the  child. 

+ Rungius,  Institut.  Chirurg.  pars  secunda,  p.  728.  Tousaint  Beauregard,  Ancien 
Journ.  de  Med-,  t.  lxxix,  p.  68.  Deneux,  from  Percy,  (loc.  cit,  p.  53.), 


RUPTURE  OF  THE  UTERUS. 


235 


proper  to  add  that  the  amniotic  fluid  alone  sometimes  escapes  into 
the  peritoneal  cavity,  but  this  effusion  is  commonly  of  little  conse- 
quence, and  never  gives  rise  to  results  so  fatal  as  those  produced  by 
the  effusion  of  blood. 

We  repeat  again,  that  rupture  of  the  womb  is  a very  dangerous, 
and  almost  always  fatal  accident.;  if  the  woman  does  not  perish  im- 
mediately from  external  or  internal  haemorrhage,  she  soon  succumbs 
under  the  influence  of  inflammation,  caused  by  sanguine  effusion 
and  the  presence  of  the  foetus  and  placenta  in  the  cavity  of  the  peri- 
toneum. Nevertheless,  death  does  not  always  follow  rupture  of 
the  uterus,  in  which  case  the  parietes  of  the  cyst  become  anew 
the  seat  of  acute  inflammation,  and  of  purulent  secretion,  which 
opens  a passage  either  upon  the  exterior  surface  of  the  abdomen, 
into  the  cavity  of  the  vagina  or  vulva,  or  into  the  rectum,  the  colon 
and  other  intestines,  as  was  observed  by  Doctor  John  Dunn,*  or  into 
the  bladder,  as  in  a case  seen  by  M.  Morlane,  and  another,  still 
more  recent,  communicated,  by  M.  Lecieux,  to  the  Societe  Medicate 
d'hnulation  of  Paris,!  or,  finally,  into  the  stomach  even,  as  Marcel- 
lus  Donatus,f  George  Salmuti,§  and  Bernard  Montana, ||  seem  to  have 
seen  examples  of,  and  certain  of  which  have  also  been  reported  by 
Thomas  Bartholin, If  Professor  of  Anatomy  at  Copenhagen.  Accord- 
ing to  the  authors  we  have  just  quoted,  the  remains  of  the  foetus, 
partly  in  a state  of  putrescence,  were  swept  off  by  the  purulent 
fluids,  and  expelled  from  the  body;  in  some  cases  through  the  anus, 
through  the  vulva,  or  by  a spontaneous  opening  in  the  abdominal 
parietes,  and  in  other  cases,  by  means  of  vomiting ; finally,  in  the 
case  by  Doctor  Lecieux,  the  bones  of  the  fetus  passed  into  the  blad- 
der, and  there  became  the  nuclei  of  several  urinary  calculi.  While 
some  women  have  perished,  because  nature  has  been  unable,  in  their 
cases,  to  produce  such  salutary  movements,  others  have  died,  be- 
cause, after  a primary  evacuation  of  the  debris  of  the  fetus,  one  of 
the  bones  of  the  latter  has  presented  across,  or  being  too  voluminous, 
has  blocked  up  the  passage  by  which  the  complete  expulsion  might 
have  been  effected. 

Of  all  the  means  of  diagnosis,  the  introduction  of  the  hand  into  the 
vagina  and  uterine  cavity,  is  that  which  is  in  all  cases  the  most  faith- 
ful, and  leaves  the  least  obscurity  upon  the  different  ruptures  of 
the  womb.  Indeed,  if  able  to  distinguish  the  fetus  with  some  cer- 
tainty by  means  of  abdominal  palpation,  and  near  it  a hard  and 
rounded  tumour  formed  by  the  more  or  less  contracted  womb,  we 
shall  discover,  by  carrying  the  hand  into  the  vagina  and  through  the 
orifice  of  the  uterus,  not  only  the  rupture  itself  and  the  place  where  it 
exists,  but  also  the  circumstances  which  accompany  it.  If  the  lacera- 
tion has  taken  place  in  the  neck,  the  chances  are  less  unfavourable, 
because  we  can  generally  extract  the  foetus  through  the  wound  and 

* The  Edinburgh  Med.  and  Surg.  Journal,  July,  1833. 

| Bulletin  de  la  Societe  Med.  d’emul.,  1822. 

\ De  Historia  mfdica  mirabili,  1586. 

§Observationuni  medicarum  centur.  posthum.,  1658. 

II  Libro  del  anat.  del  hombre,  1550. 

t De  insolitis  partus  viis,  1664. 


236 


RUPTURE  OP  THE  UTERUS. 


vagina,  without  being  obliged  to  perform  the  operation  of  gastro- 
tomy. In  all  cases,  the  prognosis  is  very  grave,  but,  as  we  have 
already  said,  the  records  of  science  possess  a considerable  number  of 
facts,  which  prove  that  women  have  recovered  from  rupture  of  the 
body  of  the  womb,  especially  when  succoured  in  time  by  skilful 
hands. 

The  most  pressing  indication  to  be  fulfilled  after  a rupture  of  the 
womb,  is,  first,  to  effect  as  soon  as  possible  the  extraction  of  the  foetus 
and  placenta,  the  presence  of  which  constitutes  the  most  unfavoura- 
ble complication,  and  then  to  combat  the  secondary  symptoms  ac- 
cording to  circumstances.  If  the  child  have  not  passed  entirely  into 
the  abdominal  cavity,  we  should  always  endeavour  to  terminate  the 
labour  by  the  natural  passages;  but  in  the  contrary  case,  recourse 
must  be  had  as  soon  as  possible  to  gastrotomy,  because  this  extreme 
means  offers  some  chance  of  safety  to  the  mother,  and  especially 
to  the  child,  which  would  indubitably  perish  unless  we  should  act 
with  great  promptitude. 

The  operation  of  gastrotomy  is  performed  in  the  following  man- 
ner : having  placed  the  female  on  a firm  bed,  with  a cushion  under 
the  hips,  in  order  to  increase  the  prominence  of  the  abdomen,  the 
operator,  placed  upon  the  left  of  the  patient,  makes  in  the  abdominal 
parietes  and  towards  the  region  occupied  by  the  child,  a longitu- 
dinal or  oblique  incision,  which  he  should  always  be  careful  to 
limit  to  an  extent  of  from  five  to  six  inches.  This  first  abdominal 
incision,  the  place  and  direction  of  which  must  be  determined  by  the 
position  of  the  foetus,  should  include  only  the  skin  and  subcutaneous 
cellular  tissue  ; then,  carrying  the  bistoury  carefully  into  the  inferior 
angle  of  the  wound,  an  opening  sufficient  to  permit  the  introduction 
of  the  fore-finger  of  the  left  hand  should  be  made ; next,  substitut- 
ing for  the  first  instrument  a probe-pointed  bistoury,  the  surgeon 
carries  this  last  into  the  abbomen  by  gliding  it  along  the  finger  re- 
tained in  the  wound,  and  cuts  the  muscles  and  aponeuroses  in  the 
same  direction,  and  to  the  same  extent,  as  the  first  incision  that  was 
made  externally.  If  large  vessels  should  be  opened  during  the 
operation,  they  must  be  tied,  or,  still  better,  twisted;  in  the  con- 
trary case,  a hand  should  be  introduced  into  the  abdomen  without 
delay,  to  extract  the  foetus  and  placenta;  yet,  if  the  latter  have 
remained  in  the  cavity  of  the  uterus,  it  would  be  better,  perhaps, 
after  having  tied  the  cord,  to  trust  its  expulsion  to  the  efforts  of 
nature. 

The  dressing  of  the  wound  is  very  simple  ; it  consists  in  the  ap- 
plication of  adhesive  strips,  and  some  pledgets  of  charpie,  covered 
with  compresses,  and  maintained  in  situ  by  means  of  a moderately 
tight  bandage  around  the  body.  In  order  to  facilitate  as  much  as 
possible  the  approximation  of  the  edges  of  the  wound,  the  patient 
must  be  placed  in  a suitable  position;  she  should  be  advised  to 
have  the  child  applied  to  the  breast,  in  order  to  diminish  the  flow  of 
the  lochia,  and  especially  to  produce  a revulsive  mammary  irritation, 
which  could  not  but  be  favourable  to  the  cure.  She  should  be  re- 
stricted to  a close  diet,  and  the  inflammatory  and  nervous  symptoms 


RUPTURE  OF  THE  UTERUS. 


237 


must  be  combated  by  the  most  powerful  antiphlogistics  and  anti- 
spasmodics,  which  ought  to  be  varied  according  to  circumstances. 
In  all  cases,  it  could  not  but  be  advantageous  to  prescribe  emol- 
lient and  anodyne  vaginal  injections,  to  which  might  be  added  the 
use  of  fomentations  and  enemata  of  the  same  kind. 

When  we  have  the  good  fortune  to  see  the  wound  cicatrize,  we 
should  advise  the  female  always  to  wear  a well-made  belly-band, 
in  order  to  sustain  the  abdominal  viscera,  and  in  this  way  prevent 
their  displacement.  These  means  have  sometimes  succeeded;  M. 
Nauche*  states  that  after  an  operation  for  gastrotomy,  performed 
by  Thibaud  Dubois,  some  hours  subsequent  to  a rupture  of  the  womb, 
the  woman,  whose  child  was  dead,  suffered  no  other  symptoms  than 
those  which  result  from  an  ordinary  labour.  Sabatiert  also  states 
that  Lambron,  a surgeon  of  Orleans,  succeeded  in  two  similar 
cases,  in  the  same  female.  Gastrotomy  was  performed  on  the 
first  occasion  twenty-four  hours  after  the  rupture,  from  which  it 
necessarily  resulted  that  the  child  was  extracted  dead ; an  abscess 
followed  in  the  neighbourhood  of  the  wound ; yet  notwithstanding 
this  complication,  the  patient  recovered,  and  became  pregnant  again 
the  following  year.  The  uterus  being  ruptured  anew,  Lambron 
performed  gastrotomy  a second  time  a few  moments  after  the  acci- 
dent ; the  child  evinced  some  signs  of  life,  but  soon  died  ; the  mother 
being  once  more  perfectly  restored,  became  pregnant  again,  and  was 
delivered,  without  accident,  of  a child,  which  survived.  This  opera- 
tion, which  does  not  always  terminate  so  happily,  and  yet  to  which 
we  should  not  hesitate  to  recur,  since  it  offers  almost  the  only  chance 
for  safety  in  a great  number  of  cases,  has  likewise  been  successfully 
performed  by  several  other  practitioners,  amongst  whom  we  deem 
it  sufficient  to  cite  MM.  Fritzel,f  Powel,§  Sommer, ||  MackenzielT  and 
Neville.** 

We  shall  terminate  what  we  have  to  say  upon  this  subject  by  add- 
ing, that  as  rupture  of  the  uterus  is  an  accident  of  the  most  serious 
character,  it  is  exceedingly  important  to  attend  to  all  the  means  proper 
for  preventing  it,  that  is  to  say,  to  remove,  as  soon  as  possible,  all 
obstacles  that  might  render  the  uterine  contractions  unavailing. 
Thus,  in  some  cases  we  shall  succeed  in  preventing  the  laceration  by 
performing  the  operation  of  turning,  or  by  restoring  the  gestative 
organ  to  its  normal  direction ; in  others,  we  shall  attain  the  same 
result  by  incising  the  cervix,  when  it  is  the  seat  of  a callosity,  or 
by  resorting  to  symphyseotomy  when  contraction  of  the  pelvis  op- 
poses the  escape  of  the  child ; and  finally,  by  employing  every  means 
proper  for  facilitating  delivery,  such  as  baths,  emollient  injections 
and  fumigations,  and  especially  general  bleedings  at  the  arm. 

Unfortunately,  lacerations  of  the  uterus  cannot,  generally,  be  either 
foreseen  or  prevented;  either  because  they  take  place  suddenly  and 

* Maladies  de  Femmes,  tom.  i.  p.  267. 

-j-  Medecine  Operatoire,  tom.  i.  p.  340. 

* Trans,  of  Iceland,  t.  i. 

9 Med.  Reposit.,  new  ser.,  t.  iv. 

**  Med.  Soc.  of  London,  Feb.  1824. 


§ Trans,  of  London,  t.  xii. 

If  London  Med.  Gazette,  Oct.  1830. 


238 


RUPTURE  OF  THE  UTERUS. 


without  precursory  symptoms,  or  else  because  women  are  attended 
by  persons  incapable  of  judging  of  their  condition  and  acting  ac- 
cordingly. 

The  Fallopian  tubes  and  ovaries,  also,  like  the  vagina  and  uterus, 
are  liable  to  laceration  when  they  become  the  seat  of  extra-uterine 
conception.  Baillie*  reports  a case  of  rupture  of  the  Fallopian  tube, 
which  occurred  from  the  progressive  development  of  a foetus  con- 
tained within  it,  and  gave  rise  to  fatal  haemorrhage ; moreover,  these 
kinds  of  laceration,  which  are  very  rare,  require  the  same  treatment 
as  that  which  has  been  indicated  for  ruptures  of  the  vagina  and  of 
the  uterus.  See  a case  in  Philad.  Prac.  Mid.,  p.  106. 

OF  VAGINAL  FISTULAS. 

The  vagina  may  communicate  by  means  of  one  or  more  acci- 
dental openings,  with  the  bladder  or  urethra  by  its  anterior  paries, 
and  with  the  rectum  by  its  posterior  paries,  or  at  the  same  time  in 
front  and  behind,  with  each  of  these  cavities.  These  kinds  of  per- 
forations constitute  what  are  called  vaginal  fistulas , which  are  dis- 
tinguished into  vesico-vaginal  and  reclo-vagin al  fistulas  ; and  into 
double  or  multiple  vaginal  fistulas,  according  to  the  situation  and 
number  of  the  perforations  in  the  vul vo-uterine  canal. 

OF  VESICO-VAGINAL  AND  RECTO-VAGINAL  FISTULAS. 

Vesico-vaginal  fistula,  that  is  to  say,  the  anormal  aperture  which 
allows  the  urine  to  enter  the  vagina  and  to  flow  off'  constantly 
through  it,  against  the  will  of  the  person  affected,  is  a physical 
lesion  which,  though  rare,  is  met  with  often  enough  to  deserve  all 
the  attention  of  men  of  art.  This  disease,  or  rather  this  disgust- 
ing infirmity,  is  one  of  the  most  unfortunate  and  painful  accidents 
to  which  women  are  liable.  In  fact,  the  inconveniences  which 
result  from  it  reduce  them  sometimes  to  such  despair,  that  they 
always  accept  without  hesitation  the  most  painful  operations,  and  all 
other  means  proposed  to  them.  Though  never  mortal  in  itself,  the 
affection  is,  nevertheless,  a very  serious  one,  not  only  from  its  reduc- 
ing the  patient  to  the  most  deplorable  condition,  but  particularly  be- 
cause of  the  great  difficulty  almost  always  met  with  in  obtaining  a 
radical  cure. 

The  causes  which  give  rise  to  vagino-vesical  fistula  are,  most 
generally,  the  prolonged  detention  of  the  foetal  head  in  the  excava- 
tion of  the  pelvis  during  laborious  labours,  and  compression  of  the 
superior  portion  of  the  vagina  against  the  symphysis  pubis,  from 
which  result  gangrenous  eschars,  whose  fall  almost  always  pro- 
duces vaginal  perforations.  To  the  causes  just  mentioned,  must  be 
added  violent  manipulations,  and  the  employment  of  the  lever  or 
forceps,  directed  by  awkward  hands,  the  prolonged  retention  of 
a calculus  or  other  foreign  body  in  the  bladder,  of  which  Fabricius 

* Anatomie  Pathologique,  chap,  xxiii.  sect.  5. 


RUPTURE  OF  THE  UTERUS. 


239 


Hildanus  cites  an  example  ;*  that,  of  a pessary  in  the  vagina, t vagi- 
nal cystotomy,  and  finally,  vesico-vaginal  fistulas  have  also  been 
known  to  occur  from  venereal  ulcerations,  or  from  a cancerous  ulcer 
situated  upon  the  neck  of  the  womb,  and  still  more  upon  the  vagino- 
vesical septum. 

The  signs  of  this  affection,  which  may  likewise  be  congenital^ 
present  but  few  differences  in  the  women  attacked  by  it.  When  it 
follows  a laborious  labour,  retention  of  urine  is  almost  always  pre- 
sent, which  is  relieved  at  first  by  the  introduction  of  a catheter  into 
the  bladder,  but  is  gradually  converted  into  complete  incontinence 
after  the  fall  of  sloughs  of  greater  or  less  size,  which  usually  takes 
place  from  the  seventh  to  the  twelfth  day. 

Vesico-vaginal  fistula  may  occur  in  the  canal  of  the  urethra,  and 
at  the  neck,  or  bas-fond  of  the  bladder.  Those  of  the  first  kind, 
to  wit,  the  urethral,  are  the  least  unfavourable,  because  the  urine 
does  not  flow  except  during  the  voluntary  expulsion  of  this  fluid, 
which  escapes  partly  by  the  meatus  urinarius,  and  partly  by  the 
accidental  perforation.  The  anormal  discharge  of  the  vesical  fluid, 
whose  quantity  varies  according  to  the  dimensions  of  the  fistula, 
by  bathing  the  wall  of  the  vagina  and  the  internal  surface  of  the 
labia  majora  almost  constantly,  soon  causes  an  active  irritation  in 
those  parts,  and  develops  in  them  either  an  habitual  erysipelatous 
condition,  or  an  eruption  of  large  pimples,  or  else  grayish  ulcerations 
and  smarting,  and  very  painful  pruritus,  which  it  is  more  difficult  to 
prevent  than  to  cure. 

When  the  perforation  is  situated  at  the  neck  of  the  bladder,  all  the 
symptoms  we  have  just  mentioned  become  still  more  serious,  for 
the  patients  are  unable  to  retain  their  urine,  except  in  a few  cases 
when  seated  or  standing,  because  the  womb  in  these  positions  gra- 
vitates, and  closes  the  fistulous  aperture,  the  lips  of  which  it 
maintains  in  contact  by  approximating  the  superior  edge  to  the  infe- 
rior. In  order  for  this  result  to  be  obtained,  it  is  necessary,  on  the 
one  hand,  that  the  perforation  shall  be  slight,  and  on  the  other,  that 
the  female  shall  avoid  the  expiratory  efforts  which  occur  in  sneez- 
ing, laughing,  spitting,  coughing  and  blowing  the  nose,  a thing 
difficult,  if  not,  indeed,  impossible.  In  reality,  every  time  that  the 
diaphragm  forces  the  abdominal  viscera  downwards  by  a sudden 
contraction,  the  bladder,  which  is  compressed  at  the  same  moment, 
likewise  contracts,  and  a change  in  the  direction  of  the  fistula  is 
produced,  which  then  allows  the  urine  to  escape,  in  spite  of  the  pre- 
cautions taken  by  the  woman. 

When  the  perforation  is  seated  at  the  bas-fond  of  the  bladder,  the 
flow  of  urine  is  continual,  no  matter  what  be  the  position  that  the 
patient  assumes.  In  this  case,  the  most  unfortunate  of  all,  their  beds, 
their  garments,  the  cavity  of  the  vagina,  and  the  internal  surface 
of  the  labia  majora,  are  constantly  bathed  with  urine,  and  there 

* Opera  omnia,  centuh  i.  observ.  68. 

f Journ,  compkm.  des  Sciences  Med.,  tom.  xxxvii.,  and  various  cases  that  we 
cited  while  treating  of  pessaries,  in  the  early  part  of  this  work. 

Die.  des  Sciences  Med.,  t.  lvi.  p.  303. 


240 


RUPTURE  OP  THE  UTERUS. 


is  no  precaution,  no  means  of  cleanliness  which  can  guarantee  them 
from  being  constantly  wet,  and  especially  from  the  urinous  and 
disgusting  odour  which  they  exhale.  There  are  some  even  who 
are  compelled  to  pass  their  lives  in  chairs  with  holes,  in  which  are 
placed  vessels  intended  to  receive  the  urine  as  it  escapes  from  the 
vagina. 

Notwithstanding  the  sad  picture  we  have  just  traced  of  vesico- 
vaginal fistulas,  they  did  not  attract  the  attention  of  surgeons  until 
the  commencement  of  the  present  century,  and  we  find  no  good  his- 
tory of  them  except  in  the  most  recent  works.  Nevertheless,  these 
kinds  of  perforation  have  existed  at  all  periods,  and  must  have  been 
more  frequent  formerly  than  at  present,  because  prior  to  the  disco- 
very of  the  forceps,  in  the  last  century,  difficult  labours  were  termi- 
nated only  by  the  efforts  of  nature  alone,  or  by  means  of  dangerous 
operations.  It  is  clear  that,  in  such  cases,  the  prolonged  pressure 
of  the  head  against  the  vagino-vesical  septum  and  symphysis  pubis, 
must  often  have  produced  gangrene,  which  is  the  most  common  and 
almost  the  exclusive  cause  of  the  affection  which  now  occupies  our 
thoughts. 

The  diagnosis  of  vesico-vaginal  fistula  rarely  presents  any  dif- 
ficulty, and,  in  general,  with  the  aid  of  the  touch  and  the  direct  ex- 
ploration by  means  of  the  speculum  vaginae,  we  may  almost  always 
discover  not  only  their  existence,  but  also  their  form,  their  situation 
and  extent.  There  are,  nevertheless,  some  circumstances  which  we 
think  ought  to  be  mentioned,  as  they  may  cause  some  obscurity  in  the 
diagnosis. 

When  incontinence  of  urine  manifests  itself  only  a few  days  after 
delivery,  we  might  confound  this  involuntary  discharge  with  that 
of  the  lochia,  and  attribute  the  diminished  escape  of  cystic  fluid  to 
an  inflammatory,  or  some  other  pathological  condition  of  the  renal 
glands.  It  is  sufficient  merely  to  mention  this  possible  cause  of  error, 
in  order  to  avoid  falling  into  it.  It  is  also  well  to  know,  that  when 
the  vesico-vaginal  fistula,  which  occurs  after  a laborious  delivery, 
is  the  result  of  a laceration  or  division,  the  incontinence  of  urine 
supervenes  immediately  after  parturition  ; on  the  contrary,  where 
the  perforation  follows  the  formation  of  a slough,  it  is  only  after 
the  falling  of  the  latter,  which  takes  place  generally  from  the 
seventh  to  the  twelfth  day,  that  the  incontinence  of  urine  becomes 
manifest.  We  should,  nevertheless,  remark,  that  the  involuntary 
expulsion  of  urine  following  a difficult  labour,  is  not  always  the 
result  of  a communication  established  between  the  vagina  and 
bladder,  since  it  may  depend  also  upon  violent  contusion  of  the 
neck  of  the  bladder,  without  formation  of  a slough.  Although, 
in  this  last  case,  the  incontinence  is  usually  of  short  duration,  it 
may  sometimes  persist  as  though  a fistula  existed,  and  give  rise  to 
difficulties  in  the  diagnosis,  which  are,  however,  readily  removed 
by  exploration  of  the  parts.  Finally,  in  order  to  terminate  what 
we  had  to  say  upon  the  circumstances  which  may  complicate  the 
diagnosis  of  vesico-vaginal  fistulas,  we  shall  add  that  the  presence  of 
a deep  slough  on  the  neck  of  the  bladder  does  not  commonly  pro- 


VESICOVAGINAL  FISTULAS. 


241 


duce  incontinence,  until  after  having  first  determined  complete  reten- 
tion of  urine. 

If,  after  a laborious  labour,  we  should  have  some  reason  to  believe 
in  the  existence  of  a fistula,  it  would  become  necessary  to  remove 
all  uncertainty  upon  the  point  at  once,  because,  in  these  cases,  the 
least  delay  may  give  rise  to  the  most  deplorable  consequences.  In  fact, 
if  we  wait  until  the  edges  of  the  perforation  have  become  cicatrized 
separately,  there  remains  no  chance  of  cure  except  from  a painful 
and  often  unsuccessful  operation.  When,  on  the  contrary,  the  pre- 
sence of  the  accident  has  been  recognized  in  good  time,  we  may 
hope  for  complete  reunion  by  the  efforts  of  nature  alone,  examples 
of  which  have  been  cited  by  Fabricius  Hildanus,*  Paletta,!  Philippe 
Peu,f  Ryan,§  Duparcque,||  Blundell,  Capuron,  and  other  authors;  or 
we  may  at  least  hope  for  some  diminution  of  the  extent  of  the  fis- 
tula, the  radical  cure  of  which  to  be  afterwards  readily  obtained  by 
means  of  cauterization. 

The  moment  we  have  any  motive  for  fear,  it  is  of  the  highest 
importance  to  assure  ourselves  as  soon  as  possible  whether  a vaginal 
perforation  exists,  for  immediately  after  delivery,  the  vagina  and 
uterine  ligaments  are  relaxed,  the  uterus  heavy,  and  the  edges  of  the 
wound  bleeding  or  in  a state  of  suppuration.  As  all  these  circum- 
stances are  very  favourable  to  the  approximation  and  agglutination 
of  the  lips  of  vesico-vaginal  fistulas,  the  chances  of  cure  would  be- 
come more  numerous  and  sure,  in  proportion  as  art  should  assist  the 
efforts  of  nature,  either  by  the  use  of  a sound,  introduced  and  main- 
tained in  the  bladder ; by  means  of  favourable  position,  and  com- 
pression of  the  abdomen ; or  by  other  means,  to  be  varied  according 
to  circumstances,  and  the  effects  of  which  would  be  less  powerful  at 
a later  period. 

It  remains  for  us  to  say,  that  vesico-vaginal  fistula,  caused  by 
laborious  labour,  is  almost  always  either  transverse  or  oblique ; those 
produced  by  other  causes  are  more  frequently  longitudinal ; aban- 
doned to  themselves,  they  commonly  incline  to  last  for  indefinite 
periods  of  time,  although,  in  a certain  number  of  cases,  they  do  con- 
tract spontaneously,  and,  as  we  have  already  stated,  even  close,  by 
the  inherent  power  of  the  organism,  and  under  the  influence  of  con- 
ditions which  it  is  difficult  to  appreciate. 

In  order  to  acquire  as  exact  an  idea  as  possible  of  the  form  and 
dimensions  of  vaginal  perforations,  M.  Lallemand,  Professor  at  the 
Faculty  of  Montpellier,  has  devised  an  ingenious  method  of  diag- 
nosis, which  consists  in  the  introduction  into  the  vagina  of  a piece 
of  wax  properly  prepared,  by  means  of  a large  porte  empreinte IT 
supported  by  the  index  and  middle  finger  of  the  left  hand.  The  wax, 

* Centur.  i.,  obser.  68  el  centur.  iii.  obser.  69. 

t Chirurgie,  deuxieme  partie,  p.  21. 

* Prat,  des  Accouchements,  p.  384. 

§ Manual  of  Midwifery. 

H Hist.  Compl.  des  dechir.  et  des  ruptures  de  Tut.,  p.  328. 

U An  instrument  for  holding  the  wax  intended  to  receive  the  impression. — Trans . 

16 


242 


VESICO-VAGINAL  FISTULAS. 


by  remaining  a few  moments  in  the  vagina,  becomes  softened;  when 
it  is  perceived  to  have  become  sufficiently  so  to  answer  the  end  pro- 
posed, it  is  raised  up  and  applied  as  closely  as  possible  to  the  fistula, 
the  impression  of  which  it  receives  with  the  varied  forms  of  its 
orifice  and  edges,  as  well  as  the  appearance  of  all  the  surrounding 
parts,  which  is  faithfully  reproduced.  In  order  to  ascertain  the  exact 
depth  of  the  seat  of  the  lesion,  all  that  is  necessary  is,  while  remov- 
ing the  wax,  to  apply  the  thumb  upon  th e porte  empreinte,  on  a 
line  with  the  orifice  of  the  vulva.  This  excellent  means  of  diag- 
nosis, to  which  it  is  always  well  to  have  recourse,  furnishes  the 
befiting  complement  of  that  preliminary  knowledge  which  is  indis- 
pensable to  the  surgeon,  in  order  for  him  to  operate  with  certainty. 

The  degree  of  curability  or  incurability  of  vesico-vaginal  fistula, 
depends  not  only  upon  its  situation  and  form,  but  also  upon  the 
nature  of  the  causes  which  have  produced  it,  upon  its  position  in 
relation  to  the  mouths  of  the  ureters,  and  finally  upon  the  absence  or 
existence  of  a division  of  these  canals  at  the  points  where  they  open 
into  the  bladder;  the  prognosis  is  likewise  more  unfavourable,  if  the 
urethra,  the  neck  of  the  bladder,  or  the  vesico-vaginal  septum  be 
partially  or  entirely  destroyed,  and  also  where  there  exists  a pro- 
trusion of  the  vesical  mucous  membrane  between  the  edges  of  the 
perforation. 

Though  it  be  contrary  to  the  general  opinion,  we  regard  those 
fistulas,  that  are  situated  behind  the  vesical  opening  of  the  ureters, 
as  being  more  favourable  than  those  situated  more  in  advance  of 
these  canals,  because,  in  the  former  case,  if  we  keep  the  patient  in  a 
more  or  less  vertical  position,  and  retain  in  the  bladder  a catheter 
which  passes  but  little  beyond  the  neck  of  the  organ,  all  the  urine 
may  escape  through  the  instrument  without  bathing  the  fistula ; on 
the  contrary,  where  the  perforation  is  in  front  of  the  ureters,  and 
especially  when  near  the  neck,  a portion  of  the  urine  constantly 
flows  over  the  perforated  point,  which  constitutes  one  of  the  greatest 
obstacles  to  spontaneous  cure,  as  well  as  to  the  agglutination  of  the 
edges  when  approximated  by  an  operation. 

Vesico-vaginal  fistulas,  which  have  been  caused  by  the  pressure 
of  a pessary  in  the  vagina,  seem,  in  general,  to  be  less  grave  than 
those  arising  from  other  causes;  for  from  the  cases  which  we  related 
while  speaking  of  the  accidents  produced  by  these  instruments,  it 
has  been  seen  that  they  often  close  spontaneously,  from  the  moment 
that  the  pessary  is  withdrawn.  We  may  say,  moreover,  that  in 
addition  to  the  circumstances  already  mentioned,  the  chances  of  cure 
are  in  proportion  to  the  diameter  of  the  opening  in  the  bladder ; the 
greater  the  loss  of  substance,  the  more  have  we  to  fear  that  art,  how- 
ever ingenious  it  may  be,  can  oppose  but  feeble  arms  to  the  disease. 

The  curative  treatment  of  vesico  and  urethro-vaginal  fistula, 
should  always  be  preceded  by  the  treatment  of  the  internal  causes 
which  may  have  produced  it,  and  by  the  removal  of  any  complica- 
tions that  might  aggravate  it.  Thus,  were  the  vaginal  perforation 
the  result  of  a syphilitic  ulceration,  it  becomes  necessary  first  to 


VESICO-VAGINAL  FISTULAS. 


243 


employ  a general  and  local  treatment  proper  for  affections  of  this 
kind.  Where  the  fistulous  opening  is  caused  by  the  presence  of  one 
or  more  calculi,  or  any  other  foreign  body  irj  the  bladder,  which  may 
be  ascertained  by  the  catheter,  or  by  the  Touch  through  the  vagino- 
vesical septum,  we  ought  to  perform  lithotomy  by  the  vagina,  or 
destroy  the  urinary  concretions  by  lithotrity,  or  by  any  other  method 
that  might  seem  more  advantageous.  If  a contraction  of  the  ure- 
thra exists,  it  should  be  treated  by  appropriate  remedies,  and  if  the 
fistula  coincide  with  large  and  projecting  callosities,  with  deep  exco- 
riations or  urinary  abscesses  of  the  labia  majora  or  nymphae,  it  should 
be  subjected  to  preliminary  treatment,  consisting  especially  in  the  use 
of  emollient  fomentations  and  lotions,  whose  action  would  be  aug- 
mented by  methodical  dressings ; in  fine,  we  should  never  think  of 
obtaining  reunion  and  agglutination  of  the  edges  of  the  fistula,  until 
after  having  restored  it  to  a simple  condition,  and  removed  all  the 
complications  capable  of  preventing  the  success  of  the  attempts  that 
we  may  make. 

Amongst  the  methods  which  have  been  employed  or  proposed  for 
the  treatment  of  fistulas,  are,  in  following  the  chronological  order,  1, 
the  palliative  method;  2,  the  use  of  the  tampon;  3,  cauterization;  4, 
the  suture;  5,  approximation  of  the  edges  of  the  perforation  by  means 
of  particular  instruments,  such  as  sounds  and  hooked  forceps,  etc. 

OF  THE  PALLIATIVE  METHOD. 

The  palliative  ought,  necessarily,  to  be  the  oldest  of  the  methods 
that  have  been  employed,  as  far  as  possible,  to  relieve  vesico-vaginal 
fistula;  for,  until  the  close  of  the  last  century,  the  cure  of  this  kind  of 
perforation  was  regarded  as  beyond  the  resources  of  surgery,  and 
especially  as  unsusceptible  of  cure  by  any  operation. 

This  method  should  be  made  use  of  only  when  the  fistula  is  known 
to  be  incurable ; that,  is  to  say,  when  it  depends  upon  the  presence 
of  an  advanced  state  of  cancer  of  the  uterus  or  vagina,  and  even 
when  it  has  been  produced  by  any  other  cause,  provided  different 
attempts  at  a cure  had  proved  unsuccessful. 

The  means  to  be  employed  in  these  unfortunate  cases  consist  of 
such  attentions  to  cleanliness  as  may  protect  the  vaginal  cavity,  the 
labia  majora,  the  perineum  and  the  thighs,  against  the  acrimony  of  the 
urine,  and,  in  the  use  of  different  contrivances  destined  to  receive  the 
fluid,  so  that  it  may  incommode  the  patient  as  little  as  possible. 

The  first  indication  is  met  by  the  frequent  use  of  baths,  of  lotions, 
and  emollient  and  narcotic  injections;  and  we  may  partially  relieve 
the  inconvenience  of  the  constant  flow  of  urine,  by  means  of  an 
instrument  which  has  been  indicated  only  by  J.  L.  Petit,  under  the 
name  of  urinal  or  Irou  d’enfer  ; but  the  real  inventor  of  which  is 
Feburier.  This  instrument,  which  may  be  found  at  all  the  bandage- 
makers,  is  a sort  of  bag  or  sac  of  India-rubber,  which  may  be  kept 
in  front  of  the  vulva,  and  introduced  in  part  into  the  vagina,  so  as 
to  receive  the  urine,  without  preventing  the  woman  from  walking 
and  attending  to  her  business.  To  answer  the  same  end,  M.  Barnes, 


244 


VESICO-VAGINAL  FISTULAS. 


of  London,  makes  use  of  a gum-elastic  bottle,  which  is  placed 
partly  in  the  vagina,  and  has  a sponge  upon  its  anterior  face, 
in  which  an  opening  is  fixed,  that  should  be  carefully  directed 
towards  the  fistula  in  such  a way  that  the  urine  may  be  absorbed. 
The  urinal  ought  to  be  removed  several  times  a day,  in  order  to 
squeeze  the  urine  out  of  it.  In  addition  to  several  other  contrivances 
of  the  same  kind,  proposed  chiefly  by  manufacturers  of  bandages 
and  gum-elastic  instruments,  we  may  resort  to  the  employment  of 
fine  sponges,  and  plugs  of  linen  introduced  into  the  vagina,  and 
renewed,  more  or  less  frequently,  in  the  course  of  the  day.  Finally, 
in  order  to  compel  the  urine  to  escape  by  the  urethra,  or  by  a sound 
or  syphon  placed  in  it,  M.  Chailly  has  proposed  the  semi-flexed  posi- 
tion on  the  abdomen;  unfortunately,  such  result  is  far  from  being 
obtainable,  and  the  experiments  made  by  MM.  Schreger  and  Sanson 
have  proved  that  women  placed  in  the  position  indicated  by  M. 
Chailly,  have  been  able  to  maintain  it  only  a short  time,  because  it  is 
too  awkward  and  painful,  and  threatens  speedily  to  produce  sloughs 
on  the  knees,  elbows  and  iliac  spines. 

TEMPORARY  PALLIATIVE  METHOD. 

In  some  cases,  the  palliative  method  ought  to  be  temporarily 
employed ; for  example,  it  should  be  resorted  to  in  cases  of  trans- 
verse and  oblique  fistula  the  edges  of  which  remain  separate,  in 
spite  of  abdominal  compression,  the  various  positions  given  to  the 
patient,  and  the  formation  of  fibrous  tissue  on  the  lips  of  the  perfora- 
tion ; we  should,  therefore,  before  commencing  a curative  treatment, 
insist,  for  a longer  or  shorter  period  of  time,  on  warm  baths  and  injec- 
tions, emollient  fumigations  directed  towards  the  sexual  parts,  and, 
in  fine,  have  recourse  to  the  employment  of  all  the  means  capable  of 
facilitating  the  descent  of  the  uterus,  and  especially  the  relaxation  of 
that  part  of  the  vagina  situated  above  the  fistulous  orifice. 

During  the  time  not  yet  very  remote,  when  it  was  supposed  that 
the  cure  of  vesico-vaginal  fistula  was  always  beyond  the  resources  of 
art,  and  especially  that  it  was  useless  to  attempt  the  radical  cure  by 
means  of  a surgical  operation,  the  palliative  method,  which  was  gene- 
rally employed  with  the  sole  view  of  diminishing  the  inconveniences 
of  a disgusting  infirmity,  was  sometimes  found  to  be  successful  in  the 
cure  of  the  patient.  Fabricius  Hildanus,*  who  died  at  Berne,  in 
1634,  relates  a complete  cure  obtained  in  this  way  in  a lady  affected 
with  a vagino-vesical  fistula,  following  a laborious  labour.  Accord- 
ing to  this  celebrated  author,  the  cure  was  obtained  by  a treatment  of 
eight  months’  duration,  which  consisted  simply  in  the  use  of  some  pur- 
gative doses,  and  of  frictions  upon  the  loins,  but  especially  in  the  fre- 
quent employment  of  injections,  composed  of  a decoction  of  barley,  of 
quince-seeds,  and  the  seeds  of  the  fenugreek  (trigonella  fcenurn  grae- 
cum),  to  which  he  added  oil  of  sweet  almonds  and  honey  of  roses. 
We  subjoin,  moreover,  the  most  important  passage  from  this  curious 

* Opera  Omnia,  centur.  iii.  observat.  69. 


OP  TAMPONNEMENT,  ETC.,  IN  FISTULA. 


245 


case  : “ Ilia  autem  continud  usa  medicamentis  (ut  dixi)  conglutinan- 
tibus,  et  per  intervalla  etiam  pargantibus,  intra  menses  octo,  non 
sine  admiratione  omnium  eorum  quibus  res  cognita  plane  curata  fuit, 
adeo  ut  nunc  Dei  optimi  maxima  gratia  ne  guttula  quidem  urinae  invo- 
luntariae  affluat,  sed  & vesica  colligatur,  retineatur  et  excernatur  non 
aliter  ac  si  antea  nunquam  male  affecta  fuisset.” 


OF  TAMPONNEMENT,  AND  OF  DESSAULT’S  METHOD. 

Recourse  has  been  had  to  a large,  cylindrical  tampon  of  linen,  intro- 
duced and  maintained  within  the  vagina,  for  the  purpose  of  closing 
the  fistula,  and  to  press  its  anterior  against  its  posterior  lip,  so  as  to 
effect  their  cicatrization,  by  keeping  the  opposite  edges  in  as  close 
contact  as  possible.  This  method,  which  was  first  employed  by 
Fabricius  Hildanus,*  Hilscher,t  Paletta,f  and  also  by  Dessault,  who 
added  the  sound  already  proposed  by  Schulzius,§  and  made  use  of  by 
Boudon,||  and  J.  Paletta,!"  seems  in  some  cases  to  have  succeeded, espe- 
cially in  the  treatment  of  urethral  fistula,  and  also  those  of  the  bladder, 
when  they  were  recent,  of  slight  extent,  and  presented  a transverse 
opening.  In  more  severe  cases,  the  use  of  the  vaginal  plug  is  al- 
most always  useless,  and  fails,  in  spite  of  ail  the  patience  of  the 
sick,  and  all  the  dexterity  of  the  physician. 

This  method,  which,  besides  the  inconvenience  of  its  rarely  attain- 
ing the  success  we  seek,  has  the  further  one  of  requiring  a protracted 
application  of  from  six  to  ten  months,  is  described  by  Dessault  in  the 
following  manner: 

That  great  surgeon,  in  his  treatise  on  urinary  diseases,  recommends 
the  introduction  into  the  bladder  of  a sound,  of  large  calibre,  with 
very  large  eyelets,  to  be  retained  by  means  of  an  apparatus  like  a 
truss;  the  circle  of  which,  being  long  enough  to  embrace  the  upper 
part  of  the  pelvis,  supports,  at  its  middle  point,  an  oval  plate,  which 
should  be  placed  on  the  pubis.  In  the  middle  of  this  plate  is  a groove, 
in  winch  slides  a silver  rod,  curved  in  such  a way  that  one  of  its  ex- 
tremities, pierced  with  a hole,  falls  over  the  vulva,  upon  a line  with 
the  meatus  urinarius.  The  rod  of  silver  is  fixed  upon  the  plate 
by  means  of  a screw.  When  all  is  arranged  in  the  mode  that  we 
have  just  described,  the  end  of  the  sound  is  passed  through  the  open- 
ing in  the  rod  traversing  the  groove. 

This  kind  of  truss,  invented  by  Dessault,  was  preferable  to  the 
double  T bandage  in  use ; to  which  ribbons  were  fastened,  carried 
over  the  outer  end  of  the  sound,  and  afterwards  attached  to  the  hair 
of  the  vulva. 

The  lips  of  the  vagino-vesical  perforation  were  then  brought  as 
close  together  as  possible,  by  means  of  a linen  plug,  introduced  into 

* Opera  Omnia,  centur.  i.  observ.  68.  f Chirurg.,  de  Haller,  tom.  iii.  § 599. 

* Chirurg.  deuxieme  partie,  (loco  citat.) 

§ Deuxieme  Supplement  aux  oeuvres  de  Frederic  Hoffman. 

11  Traite  des  Accouch.,  conten.  des  observ.  import,  par  Nicolas  Puzos,  p.  138. 

H Chirurg , (loco  citat.) 


246 


CAUTERIZATION  OF  VAGINAL  FISTULAS. 


the  vagina,  and  pushed  from  without  inwards,  in  order  that  the 
fistulous  opening  might  in  this  way  be  entirely  closed,  and,  at  the 
same  time,  be  converted  into  a transverse  slit. 

This  method,  the  only  one  of  which  Professor  Boyer  treats,  and 
which,  as  we  have  proved,  ought  not  to  be  attributed  to  Dessault, 
except  as  regards  the  truss,  was  employed  several  times,  with  success, 
by  that  great  surgeon,  who,  however,  reports  but  a single  case,  that  of 
a female,  which  appears  to  have  been  cured.  As  it  required  months, 
and  even  years,  of  the  permanent  use  of  the  plug  and  sound,  to  obtain 
any  results,  we  think  that  the  cures  which  have  been  thought  to 
result  from  the  employment  of  such  means,  might  have  occurred,  in 
most  of  the  cases,  spontaneously,  or  at  least  with  the  aid  of  a sound 
retained  in  the  bladder. 

Though  we  must  reject,  in  general,  the  method  indicated  by  Des- 
sault, we  believe  that  in  cases  of  perfectly  transverse  fistula,  it  might 
often  be  used  with  advantage,  provided  some  modifications  that  we 
are  about  to  mention  were  made  in  it. 

In  the  first  place,  before  introducing  a tampon  into  the  vagina, 
it  would  be  necessary,  in  order  to  place  the  wound  in  the  best  possi- 
ble condition,  to  cauterize  the  cicatrized  edges  separately,  taking  care 
to  act  principally  upon  the  angles  where  the  agglutination  always 
commences. 

In  case  the  edges  of  the  fistula  should  be  very  much  separated, 
that  is  to  say,  if  it  were  a very  large  one,  and  almost  circular  in 
shape,  instead  of  resorting  to  cauterization,  we  ought,  in  order  to 
give  to  the  oval  perforation  as  much  as  possible  the  form  of  a button- 
hole, which  is  the  most  favourable  to  reunion, — we  ought,  we  say, 
in  the  first  place,  to  enlarge  it  a little,  in  the  direction  of  its  greatest 
diameter,  by  means  of  a small  incision,  half  a line,  or  a line,  on  either 
side,  and  then  freshen  the  lips  of  the  opening,  as  we  shall  show  in 
speaking  of  other  methods  of  operation. 

The  plug,  introduced  into  the  vagina,  should  be  a sort  of  pessary, 
made  of  gum-elastic,  of  a conoidal  form,  with  its  base  upwards,  whose 
circumference  should  not  be  prolonged  beyond  some  five  or  six  lines, 
so  as  to  press  backwards  the  anterior  edge  of  the  fistula,  by  means 
of  the  transverse  tension  which  would  be  produced  in  the  direction 
of  the  greatest  diameter  of  the  aperture : finally,  the  forward  pres- 
sure, or  rather  the  approximation  of  the  posterior  lip,  would  be  faci- 
litated by  the  weight  of  the  womb,  rendered  slightly  prolapsed  by 
means  of  a reclining  position  directed  for  the  patient,  and,  with  the 
aid  of  a bandage  around  the  trunk,  designed  to  fix  both  the  sound 
and  the  pessary. 


OF  CAUTERIZATION. 

Cauterization,  though  seeming  at  first  view  to  tend  merely  to  in- 
crease the  loss  of  substance  and  the  extent  of  the  perforation,  was 
used  with  success  by  Monteggia,*  and,  in  like  manner,  by  Dupuy- 


Maladies  Chirurgicales,  t.  v.  p.  339. 


CAUTERIZATION  OF  VAGINAL  FISTULAS. 


247 


tren ; it  constitutes,  nevertheless,  one  of  the  best  means  which  the  art 
can  oppose  to  vesico-vaginal  fistula.  This  method,  the  happy  results 
of  which  are  especially  observable  where  the  perforation  is  of  small 
extent,  is  worthy  qf  all  attention  from  practitioners ; but,  in  order  that 
it  may  be  crowned  with  success,  we  must  know  how  to  apply  it  pro- 
perly, and  according  to  certain  rules  which  we  shall  soon  describe. 

Cauterization  should  be  practised  only  with  the  actual  cautery,  or 
with  the  nitrate  of  silver ; and  we  should  always  reject  as  useless, 
and  even  injurious,  both  the  acid  nitrate  of  mercury,  and  the  concen- 
trated acids  which  were  first  employed  by  Professor  Dupuytren.  The 
nitrate  of  silver  is  generally  preferable ; and  we  should  resort  to  the 
incandescent  wire,  which  acts  more  rapidly  and  with  greater  energy, 
only  where  the  edges  of  the  fistula  are  hard,  callous  and  difficult  to 
irritate. 

Whether  we  use  one  or  the  other  of  these  two  modes  of  cauteri- 
zation, the  patient  must  be  placed  in  the  position  which  we  have 
advised  for  the  application  of  the  speculum,  that  is,  on  the  back,  with 
a folded  sheet  under  the  hips,  the  head  supported  by  pillows,  the 
thighs  flexed  upon  the  abdomen,  the  legs  upon  the  thighs,  which 
should  be  separated  and  firmly  held  by  assistants.  Nevertheless,  to 
prevent  the  urine  from  extinguishing  the  cautery  too  soon,  when  the 
wire  is  used,  it  would,  perhaps,  be  convenient  to  place  the  female  in 
the  opposite  position,  that  is  to  say,  on  the  hands  and  knees.  Should 
we  adopt  this  last  method  of  cauterization,  it  becomes  necessary,  in 
order  to  protect  the  surrounding  tissues,  and  leave  only  the  fistula 
uncovered,  to  introduce  into  the  vagina  a common  cylindrical  spe- 
culum, but  having,  in  the  whole  or  a part  of  its 
length,  a fenestra  placed  so  as  to  correspond  to 
the  vaginal  perforation.  When  all  has  been  thus 
arranged,  we  must  apply  to  the  circumference  of 
the  fistula  a large  stilet,  heated  to  a white  heat,  or  a 
small  cautery,  in  the  shape  of  a bean,  which  we 
must  be  careful  to  retain  in  contact  only  a few 
moments,  in  order  to  irritate  merely  the  edges  of 
the  wound,  and  not  to  erode  and  destroy  them  by 
prolonging  the  application  of  the  heat  too  long. 

Professor  Delpech,  who,  like  Dr.  Bellini,  of  Rovigo, 
has  successfully  employed  the  actual  cautery, 
thinks  that  it  should  be  applied  less  to  the  vesical 
portion  than  to  the  vaginal  circumference  of  the 
fistula,  so  as  to  prevent,  as  far  as  possible,  loss  of 
substance,  while  producing  the  irritation  necessary 
to  effect  the  contraction  of  the  lips  of  the  wound 
and  its  cicatrization. 

To  perform  the  operation  of  cauterization  with  nitrate  of  silver,  the 
patient  should  be  placed  as  we  have  above  directed,  and  the  specu- 
lum should  likewise  be  applied  according  to  the  rules  which  we  have 
just  laid  down.  After  having  fixed  a piece  of  solid  lunar  caustic  in 
a port-crayon,  by  means  of  a thread,  in  such  a way  that  it  may  form 
a right  angle  with  the  blades  of  the  instrument,  the  surgeon  should 


248 


CAUTERIZATION  OF  VAGINAL  FISTULAS. 


carry  the  caustic  into  the  vagin  o-vesical  aperture,  and  rub  it  during  a 
proper  period,  on  the  edges  and  angles  of  the  wound,  which  latter  he 
should  in  particular  cauterize  completely ; for  it  is  there,  as  we  have 
already  said,  that  the  agglutination  always  commences.  In  order 

to  prevent  the  hand  from 
masking  the  parts,  and  to 
render  the  operation  very 
easy, whatever  be  the  form, 
extent  and  situation  of  the 
fistula,  we  have  caused  a 
caustic-holder  to  be  made, 
whose  handle  is  bent  at 
nearly  a right  angle,  while 
its  anterior  extremity  is 
movable,  so  that  it  may 
act  in  all  directions.  This 
instrument,  which  resem- 
bles the  letter  Z,and  which 
we  have  called  a vagino- 
causte , is  merely  a modi- 
fication of  the  caustic-hold- 
er, which  we  daily  use  for 
the  cauterization  of  the 
tonsils  and  the  walls  of  the  pharynx.  ( See  Jig.  22.) 

In  whatever  mode  the  cauterization  may  have  been  performed,  it 
is  useful  to  resort  at  once  to  emollient  injections,  and  to  place  the 
patient  in  a warm  bath,  in  order  to  diminish  the  pain  which  follows 
the  operation,  and  prevent  too  intense  an  inflammation,  which  might 
supervene. 

In  general,  a single  cauterization  with  the  nitrate  of  silver  is  not 
sufficient  to  freshen  the  edges  of  the  fistula,  especially  when  it  is  hard 
and  callous ; in  this  case,  it.  becomes  necessary  to  repeat  the  operation, 
allowing  four  or  five  days  of  interval  between  each  cauterization,  to 
permit  the  slough  to  fall ; finally,  when  the  edges  are  fully  renewed, 
a catheter  should  be  introduced  and  retained  in  the  bladder,  so  that 
the  urine,  escaping  freely  into  a vessel  placed  in  front  of  the  vulva, 
may  not  prevent  the  approximation  of  the  parts.  As  long  as  the 
occlusion  of  the  aperture  remains  imperfect,  we  should  persevere  in 
these  measures,  especially  if  we  perceive  that  the  diameter  of  the 
fistula  gradually  diminishes. 

We  shall  conclude  by  saying  that  cauterization  favours  the  cica- 
trization of  vesico-vaginal  fistulas  by  three  simultaneous  modes  of 
action ; 1,  by  freshening  the  edges  of  the  orifice,  and  thus  placing  them 
in  a condition  favourable  to  their  cohesion ; 2,  by  inducing  tumefac- 
tion of  the  edges,  and  producing  a new  tissue  (modular  tissue), 
whose  contraction  contributes  powerfully  to  the  approximation  of 
the  parts ; 3,  by  modifying  the  nature  and  vitality  of  the  vagino- 
vesical mucous  membranes,  and  destroying  the  epithelium,  which, 
in  its  natural  state,  is  the  principal  obstacle  to  their  cohesion  when 
put  in  contact ; finally,  we  shall  add  that  cauterization  is  commonly 


Fig.  22. 


THE  SUTURE  IN  VAGINAL  FISTULAS. 


249 


followed  by  success,  only  in  small  fistulas  and  in  urethro-vaginai 
fistula;  as  it  almost  always  fails  in  those  extensive  perforations 
that  we  most  desire  to  cure,  it  should  be  rejected  in  severe  cases, 
while,  in  order  to  terminate  the  cure  of  fistulas  that  we  have  suc- 
ceeded in  diminishing,  recourse  is  always  to  be  had  to  one  of  the 
methods  yet  to  be  described. 

OF  THE  SUTURE. 

The  use  of  the  suture,  in  the  cure  of  vaginal  fistula,  dates  *only 
from  the  early  part  of  this  century.  J.  L.  Petit*  thought  it  so  in- 
effectual, that  he  violently  contended  against  the  advice  of  a physi- 
cian called  in  consultation  with  several  others,  on  a lady  affected 
with  vesico-vaginal  fistula.  This  celebrated  surgeon,  who  died  in 
1750,  says,  in  his  posthumous  works  published  by  Lesue,  his  former 
pupil,  that  the  consulting  physician  who  proposed  the  suture,  and 
who,  moreover,  stood  alone  in  his  opinion,  adopted  the  common 
opinion,  because  he  made  him  feel  “ not  only  the  difficulty  of  per- 
forming the  operation  in  a part  so  deep-seated  and  obscure ; but, 
also,  the  necessity  of  freshening  the  edges  of  the  whole  circum- 
ference of  the  perforation,  and  the  impossibility  of  doing  it  com- 
pletely/’ 

According  to  M.  Chelius,  to  whom  Professor  Velpeaut  refers,  the 
suture  was  proposed  by  Roonhuysen,  an  accoucheur  and  surgeon  at 
Amsterdam,  who  flourished  about  the  middle  of  the  seventeenth 
century,  and  was  celebrated  as  the  inventor  of  the  lever,  which  was 
for  a long  time  a secret  as  to  the  public.  The  method  of  Roonhuy- 
sen, which  appears  to  have  been  pointed  out  to  him  by  his  nephew, 
consisted  in  freshening  the  edges  of  the  fistulous  orifice,  re-uniting 
them  by  means  of  needles  made  of  pieces  of  swan-quill  maintained 
by  the  twisted  suture,  and,  lastly,  in  filling  the  vaginal  cavity  with 
sponge.  It  would  seem  that  this  method  afterwards  succeeded  in 
the  hands  of  Fatio  and  Walter ; but  the  proofs  we  have  of  their  suc- 
cess are  not  sufficiently  conclusive  and  authentic  to  remove  all  doubt 
in  regard  to  it. 

M.  Lewzinski  proposed  the  suture,  in  a thesis  defended  before 
the  Faculty  of  Medicine  of  Paris  in  1802.  The  instrument  that  he 
recommends  for  the  operation,  is  simply  a flat  catheter,  slightly 
curved,  and  pierced  with  two  holes  at  its  vesical  extremity,  so  as  to 
give  passage  to  a needle  also  curved.  After  the  catheter  has  been 
introduced  into  the  bladder,  “the  needle  is  pushed  along  the  vagina 
through  the  posterior  lip  of  the  fistula,  by  means  of  a watch-spring, 
contained  in  the  hollow  of  the  instrument.  The  needle,  which  has 
thus  traversed  the  vesico-vaginal  septum,  is  immediately  withdrawn 
through  the  vulva,  bringing  along  with  it  a thread,  of  which  a suture 
point  is  made,  after  having  perforated  the  opposite  lip  of  the  wound ; 
finally,  when  a number  of  threads  sufficient  to  keep  the  edges  of  the 


* Traite  des  Maladies  Chirurg.  et  des  Operat.  etc.,  tom.  iii.  p.  87. 
\ Medecine  Operatoire,  tom.  iii.  p.  648. 


250 


THE  SUTURE  IN  VAGINAL  FISTULAS. 


division  in  contact  have  been  in  this  manner  adjusted,  they  are  knot- 
ted and  secured  by  means  of  a serre-noeud. 

M.  Nsegele,  professor  at  Heidelberg,  used  the  suture  successfully 
in  1812.  For  its  application  he  proposes  several  methods,  which 
we  shall  describe,  after  explaining  the  mode  he  takes  to  freshen 
the  edges  of  the  wound,  and  which  he  executes  in  the  following 
manner : After  introducing  a catheter  into  the  bladder,  which  ought 
to  be  held  there  firmly,  he  carries  a pair  of  sharp-pointed  scis- 
sors into  the  vagina,  by  conducting  them  along  the  fore-finger,  and 
with  them  dissects  the  tissues  so  as  to  revive  the  edges  of  the  fistula 
which  are  supported  by  the  catheter.  If  this  cannot  be  completed 
with  the  scissors,  he  terminates  it  by  means  of  a bistoury  with  a con- 
cealed blade,  which  is  projected  as  soon  as  it  comes  in  contact  with 
the  parts  on  which  it  should  act.  When  the  edges  of  the  fistula 
have  been  sufficiently  renewed,  Professor  Naeg&le  proceeds  to  the 
ligature,  first,  by  means  of  a needle,  like  Deschamp’s  needle,  for  the 
ligature  of  the  popliteal  artery.  This  needle,  mounted  upon  a ring 
in  which  the  fore-finger  of  the  right  hand  engages,  is  carried  on  the 
left  index,  which  covers  its  point,  until  it  reaches  that  part  of  the 
edge  of  the  fistula  which  we  wish  to  puncture.  Then  the  finger, 
which  now  ceases  to  cover  the  point  of  the  needle,  supports  the  lip  of 
the  wound  during  the  puncture,  which  takes  place  first  from  the 
vagina  towards  the  bladder,  and  then  from  the  bladder  towards  the 
vagina  for  the  opposite  side. 

As  soon  as  the  point  of  the  needle  appears,  after  traversing  the 
vesico-vaginal  septum,  the  ligature,  which  is  carried  by  an  eye  in  the 
needle,  is  disengaged,  and  the  needle  itself  withdrawn  by  a retro- 
grade movement,  in  order  to  arm  it  with  a new  thread,  so  as  to 
apply  as  many  sutures  as  may  be  deemed  necessary.  Finally,  the 
operation  is  terminated  by  uniting  the  ends  of  all  the  ligatures,  which 
are  twisted  and  their  ends  secured  by  nfeans  of  adhesive  strips,  after 
which,  with  the  view  of  supporting  the  anterior  wall  of  the  vagina,  a 
quantity  of  charpie  is  introduced  into  the  cavity. 

M.  Nsegele  proposes  another  method  which  consists  in  piercing 
the  edges  of  the  fistula  with  curved  needles,  each  held  in  a pair  of 
forceps;  when  the  needles  have  perforated  the  vaginal  septum,  they 
are  left  in  situ,  and  after  having  withdrawn  the  forceps,  are  sur- 
rounded by  a waxed  thread  which  approximates  the  edges  of  the 
wound,  in  the  manner  of  the  twisted  suture. 

Finally,  M.  Nsegele  has  described  a third  method,  which  differs 
so  little  from  that  of  M.  Lewzinski,  that  we  deem  it  sufficient  to  state 
that  it  is  also  executed  by  means  of  a curved  catheter  containing  a 
spring  terminated  by  a spear-point,  the  eye  of  which  carries  a waxed 
thread.  The  mechanism  and  application  of  the  instrument  are  in 
other  respects  the  same  as  in  the  proceeding  of  M.  Lewzinski. 

M.  Ehrmann,  of  Strasbourg,  and  also  M.  Deyber,  have  succeeded 
in  curing  vagino-vesicai  fistula,  by  means  of  the  suture,  applied 
with  a curved  needle,  that  was  carried  into  the  vagina  upon  a port- 
needle,  ( porte-aiguille ,)  similar  to  that  which  Professor  Roux  makes 
use  of  for  staphyloraphy.  The  ligatures  were  crossed  in  such  a 


THE  SUTURE  IN  VAGINAL  FISTULAS. 


251 


way  that  the  end  of  the  first  escaped  by  the  right  side,  and  the 
other  at  the  opposite  side.  The  second  ligature  was  placed  in  the 
opposite  direction,  and  then  all  the  ends  knotted  on  each  side. 

M.  Schreger,  who  had  brilliant  success  with  the  suture  of  Pelle- 
tier, has  practised  it  by  means  of  a curved  needle  and  forceps  of  a 
peculiar  kind ; when  the  ligatures  had  been  put  in  situ,  he  passed 
their  extremities  through  a number  of  beads  and  then  made  a knot 
on  the  last  one. 

M.  Chranam  has  also  used  the  suture  with  success,  employing 
the  same  method  nearly  as  MM.  Ehrmann  and  Deyber : at  the  end 
of  five  days,  the  ligatures  fell  off’  without  the  knots  having  been  un- 
tied, and  the  cure  was  perfect. 

Again,  on  the  28th  August,  1828,  M.  Malagodi  of  Bologna,  was 
as  fortunate  as  the  gentleman  we  have  just  cited,  in  the  application 
of  the  suture  for  uniting  the  edges  of  a vesico-vaginal  fistula : this 
dexterous  surgeon  describes  the  operation  himself  in  the  following 
words  : 

“ I introduced  the  index  of  the  right  hand,  covered  by  a leather 
finger-stall,  into  the  fistulous  opening ; I flexed  the  two  last  phalanges 
into  the  shape  of  a hook,  and,  dragging  the  left  callous  edge  of  the 
opening  downwards,  drew  it  as  near  to  the  orifice  of  the  vagina  as 
possible  : I then  took  a straight  bistoury  in  my  other  hand,  and  cutting 
upon  my  finger,  made  a semi-lunar  incision  in  the  edge  which  I had 
caused  to  project.  I repeated  the  same  operation  on  the  opposite  side, 
changing,  of  course,  the  hand ; that  is  to  say,  introducing  the  left, 
and  operating  with  the  right  hand.  By  freshening  in  this  way  the 
edges  of  the  wound,  I had  not  yet  attained  the  end  which  I sought 
to  establish,  namely,  union  by  the  first  intention.  Three  pieces  of 
ligature,  having  at  each  of  their  extremities  a very  small  curved 
needle,  and  a rod  upon  which  the  needles  could  be  fixed  and  left  at 
will,  were  the  instruments  with  which  I had  provided  myself  to 
eflect  this  reunion.  I introduced  the  right  index  finger  into  the  fresh- 
ened opening,  so  that  the  back  of  the  hand  was  towards  the  body  of 
the  patient,  the  thumb  below  and  the  little  finger  above,  and  then 
drew  into  sight  the  left  lip  of  the  vagino-vesical  orifice.  Pushing 
with  the  left  hand,  a needle  fixed  in  its  handle,  I now  engaged  it 
near  the  posterior  angle  of  the  wound,  making  it  penetrate,  with 
the  aid  of  the  fingers,  from  behind  forwards.  After  this  first  needle, 
I passed  a second  in  the  same  way,  then  a third,  at  equal  distances; 
so  that  having  repeated  the  operation  on  the  opposite  side,  I tied  the 
ligatures,  two  and  two,  and  could  then  bring  the  edges  of  the  wound, 
throughout  their  whole  length,  which  I had  before  made  to  corre- 
spond by  the  two  semilunar  incisions,  into  immediate  contact. 

“ I placed  the  patient  in  bed,  and  cautioned  her  to  lie  upon  her 
back.  I introduced  a catheter  into  the  bladder,  through  the  urethra, 
which  was  to  remain  there,  to  conduct  the  urine  discharged  by  the 
ureters,  into  a vessel  placed  below.  This  precaution  seemed  to  me 
indispensable,  lest  the  retention  of  the  urine  might  interfere  to  pre- 
vent the  immediate  reunion  which  I sought  to  obtain. 

“ During  the  second  day,  the  urine  passed  through  the  catheter,  and 


252 


THE  SUTURE  IN  VAGINAL  FISTULAS. 


not  a drop  by  the  wound.  It  was  not  so  on  the  following  day,  when 
I found  the  charpie  which  I had  introduced  into  the  vagina  bathed 
with  urine ; on  the  fourth  day  I placed  the  patient  in  the  position  for 
the  operation.  I saw  that  the  two  posterior  points  of  suture  had 
maintained  themselves;  I removed  them, and  the  reunion  was  found 
to  be  quite  perfect  where  the  edges  had  remained  in  contact.  The 
anterior  suture  point,  on  the  contrary,  had  lacerated  the  left  lip  of  the 
wound ; from  which  it  happened  that  about  one-third  of  the  primary 
opening  had  not  cicatrized. . I did  not  despair,  nevertheless,  of  ob- 
taining a complete  cure,  even  though  cauterization  with  the  nitrate 
of  silver  had  produced  no  advantage  when  the  fistulous  opening 
allowed  of  the  passage  of  the  finger : I hoped  that  the  same  remedy 
might  be  more  efficacious  now,  when  the  opening  had  been  reduced 
to  the  diameter  of  an  ordinary  catheter.  I had  recourse,  therefore,  to 
cauterization,  and  at  the  end  of  about  three  weeks,  obtained  a sen- 
sible amelioration.  The  catheter  was  constantly  kept  in  the  bladder. 
I continued  the  use  of  the  caustic  during  some  weeks,  and  the  patient 
was  entirely  cured  towards  the  beginning  of  January.” 

Though  the  suture  be  of  very  difficult  application,  and  even  while 
its  employment  has  not  been  crowned  with  success  in  the  hands  of 
such  skilful  practitioners  as  MM.  Roux,  Dieffenbach,  Duges,  Ro- 
bouham  and  some  others,  we  yet  believe  that  it  is  the  best  means  we 
can  make  use  of  in  cases  of  transverse  and  oblique  fistulas,  the  edges 
of  which  cannot  be  properly  approximated,  and  the  cure  obtained 
either  by  cauterization,  or  by  the  methods  of  which  we  have  yet  to 
speak  of. 


METHOD  OF  THE  AUTHOR. 


With  a view  to  render  the  application  of  the  suture  incomparably 
more  easy,  we  have  invented  various  instruments  and  methods,  which 
differ  according  to  the  direction  of  the  vagino-vesical  perforation. 

When  the  diameter  of  the  opening  is  large,  and  presents  itself  in  a 
longitudinal  direction,  that  is  to  say,  antero-posteriorly,  we  resort  to 
the  continuous  suture,  (whip  suture — furrier’s  suture,)  which  is  em- 
ployed advantageously  for  the  union  of  wounds  of  the  intestines  and 
stomach,  and  proceed  to  its  application  in  the  following  manner : 

Having  placed  the  woman  in  the  position  described  in  speaking  of 
cauterization,  and  exposed  the  fistula  by  means  of  a spend  urn , with  a 
longitudinal  fenestra,  ( vid.  Jigs . 25, 26, 27,)  we  seize  one  of  the  edges 
with  a pair  of  forceps,  made  movable,  and  so  arranged  that  they  can 
act  in  every  direction,  whatever  be  the  direction  of  the  wound.— (See 


Jig.  23.)  The 
edge,  held  in 
the  forceps,  is 
then  remov- 
ed by  means 
of  a small 
probe  - point- 


Fig.  23. 


ed,  double-edged  blade,  nine  or  ten  lines  in  length;  this  blade,  mounted 


thf  suture  in  vaginal  fistulas. 


253 


vertically  and  at  right  angles,  upon  an  iron  rod,  four  or  five  inches 
long,  and  terminated  by  a handle,  curved  like  that  of  the  speculum, 
may  be  turned  so  as  to  cut  from  before  backwards,  from  right  to  left, 
or  obliquely,  according  to  circumstances.— {See  Jig.  24.) 


Fig.  24. 


We  have  also  invented,  for  the  purpose  of  freshening  the  edges 
of  the  fistula,  a pair  of  long  forceps,  whose  blades,  one  cutting, 


254 


THE  SUTURE  IN  VAGINAL  FISTULAS. 


Fig.  28.  and  the  other  terminating  by  a small  leaden 
...  . . plate,  intended  to  sustain  the  tissues  during  their 
suture,  are  movable,  like  those  of  the  other  for- 
ceps, and  so  arranged  as  to  act  in  all  directions. 
— [See  Jig.  28.)  Moreover,  whichever  of  these 
instruments  we  may  choose,  we  should  take  care 
to  enlarge  the  angles  of  the  fistula  half  a line,  or  a 
line,  at  most,  with  the  small  double-edged  blade,  so 
that  the  renewal  maybe  quite  perfect  at  these  points 
where  the  cicatrization  always  commences,  and 
also  to  give  to  the  perforation  as  nearly  as  possible 
the  form  of  a button-hole,  which  is  very  favourable 
to  the  reunion  and  agglutination  of  the  parts. 

After  finishing  this  first  step  in  the  operation, 
which  is  properly  regarded  as  the  most  difficult, 
and  that  upon  which  success  in  great  measure 
depends,  we  approximate  the  raw  edges,  by  means 
of  a spiral  needle  like  a cork-screw.  This  needle, 
fixed  upon  an  ivory  handle,  has,  at  its  sharp  extre- 
mity, a small  spear-head,  three  or  four  lines  long ; 
and  at  the  opposite  end,  that  is  to  say,  at  its  point 
of  union  with  the  real  instrument,  an  eye  armed 
with  a ligature,  which  is  lodged  in  a groove, 
formed  in  the  external  edge  of  each  circumvolu- 
tion, and  there  secured  by  a small  screw,  with  a 
projecting  head. — ( See  Jig.  29.) 

Fig  29.  We  introduce  the  perfo- 

rating instrument,  thus 
armed  with  its  ligature, 
into  the  cavity  of  the 
speculum,  to  a point  cor 

responding  with  the  inferior  angle  of  the  fistula,  then,  commencing 
upon  its  vesical  aspect,  we  perforate  the  left  lip  two  lines  from  its 
edge,  and  causing  the  handle  of  the  needle  to  execute  a movement  of 
demi-rotation  with  the  fore-finger  and  thumb,  and  afterwards  a slight 
see-saw  movement  from  above  downwards,  and  from  left  to  right, 
pierce  the  opposite  edge,  which  is  traversed,  therefore,  in  a con- 
trary direction,  that  is  to  say,  from  the 
vagina  to  the  bladder. — [See  Jig.  30.) 
We  continue  the  same  process  until 
the  lips  of  the  perforation  are  com- 
pletely approximated  throughout  their 
whole  extent ; then,  with  the  blades  of 
the  forceps,  which  have  served  to  fix 
the  edges  of  the  fistula  during  the  operation, 
we  seize  the  spear-head,  to  render  it  immo- 
vable, while  we  impart  a slight  rotary  move- 
ment to  the  rest  of  the  needle  from  the  oppo- 
site side.  To  prevent  the  ligature  from  being 
loosened,  its  two  ends,  brought  out  at  the 


we 


Fig.  31. 


THE  SUTURE  IN  VAGINAL  FISTULAS. 


255 


vulva,  are  twisted  together  throughout  their  length,  and  then  fastened 
close  to  the  suture  by  means  of  a small  portion  of  sealing  wax, 
heated  until  softened. — (See  jig.  3i.)  When  we  suppose  the  union 
to  be  perfect,  we  cut  the  threads,  above  the  point  where  they  are 
fastened  by  the  wax,  and  carefully  withdraw  them. 

This  method  has  the  advantage  of  being  more  easily  applied  than 
any  of  the  others,  and  also  of  perfectly  uniting  the  lips  of  longitudi- 
nal fistulas,  by  means  of  the  whip-suture,  which  is  more  regular  and 
equal  even  than  when  made  in  cloth,  with  a common  needle.  We 
must,  moreover,  recall  to  the  reader’s  attention,  that  it  was  to  the  use 
of  the  whip-suture  that  M.  Schreger  is  indebted  for  the  success  we 
have  above  related. 

As  our  spiral  needle  is  applicable  only  in  cases  of  longitudinal 
fistula,  we  have  invented  other  needles  for  the  treatment  of  trans- 
verse and  more  or  less  oblique  vagino-vesical  perforations  by  suture. 

The  needles,  two  in  number,  are  arranged  as  follows : a shank, 
mounted  upon  a handle,  bent  at  an  obtuse  angle,  forms  a kind  of  for- 
ceps from  its  upper  and  third  portion,  and  is  then  divided  into  two 
blades,  which  are  afterwards  curved  vertically  at  a right  angle,  and 
which  again,  at  the  distance  of  eight  or  nine  lines,  are  once  more  curved 
for  about  a line,  in  order  to  sei^e  by  their  approximation  by  means  of 
a sliding-ring,  a little  spear-point,  of  about  three  lines  in  length,  the  end 
of  which  descends  again  parallel  to  the  ascending  shank. — ( See  Jig.  32.) 


Fig.  32. 


This  perforating  extremity  of  the  instrument  has,  at  its  other  end, 
an  eye,  into  which  a ligature  is  passed  and  lodged  in  a groove  cut 
in  the  length  of  the  shank,  and  secured  by  means  of  a small  screw- 
head,  placed  near  the  handle. — ( See  Jig.  33.)  The  only  difference 
between  the  two  needles  is  that  the  spear- 
F,§-33-  point  of  the  one  which  serves  to  pass  the 

^ ligature  through  the  posterior  edge  of  the  fis- 
tula,  descends  again  in  front  of  the  vertical 
shank,  while  that  which  is  designed  to  place 
the  ligature  in  the  lip  nearest  the  vulva  is  terminated  by  a little 
spear-point,  which  is  behind  the  same  shank. — (See  Jig.  34.) 

After  the  edges  of  the  fistula  have  been  freshened,  by  means  of 
the  instruments,  and  in  the  mode  described  above,  we  carry  into  the 
cavity  of  the  speculum  and  up  to  the  fistula,  the  needle  whose  perfo- 
rating extremity  is  beyond  the  vertical  shank,  (Jig.  33,)  and  after 
introducing  it  into  the  bladder  through  the  fistulous  orifice,  lower  the 


256 


THE  SUTURE  IN  VAGINAL  FISTULAS. 


whole  instrument  until  slight  resistance  is 
felt  from  the  perforation  of  the  posterior  lip, 
which  ought  to  be  made  about  two  or  three 
lines  from  its  edge,  not  by  strongly  pressing 
upon  it,  as  this  would  endanger  laceration, 
but  by  gentle  lateral  movements.  Then, 
removing  the  slide  which  held  the  blades 
together,  and  disengaging  the  ligature  still 
fixed  to  the  instrument,  we  remove  the  lat- 
ter from  the  speculum,  and  by  means  of  the 
forceps  with  movable  blades,  which  served 
to  sustain  the  parts  during  their  renewal  and 
perforation,  seize  the  spear-point  which  pro- 
jects into  the  vagina,  and  bring  it  towards 
the  vulva,  in  order  to  separate  from  it  the  ligature,  one  of  whose 
ends  is  withdrawn  from  the  wound. 

Having  applied  as  many  points  of  suture  as  necessary  in  the  pos- 
terior edge  of  the  fistula,  we  place  the  same  number  with  the  other 
needle,  in  the  anterior  lip,  taking  care  that  each  suture  be  made  with 
the  same  thread ; that  is  to  say,  that  the  largest  end  of  each  thread, 
placed  in  the  posterior  lip,  shall  serve  for  the  opposite  and  corre- 
sponding point  of  the  anterior  lip,  and  so  as  to  the  others.  Finally, 
when  all  the  sutures  have  been  inserted  in  both  edges  of  the  fistula, 
we  readily  recognize  the  ends  which  correspond,  and  which  should 
be  tied  together,  by  means  of  the  precaution  we  always  take  to  place 
a white  thread  for  the  first  ligature,  a red,  or  some  other  striking 
colour,  for  the  second,  a black  for  the  third,  etc.  This  precaution, 
which  may  seem  puerile,  or,  at  least,  useless,  to  some  persons,  lessens 
very  considerably  the  time  taken  up  in  ascertaining  the  ends  of  the 
several  ligatures.  This  done,  we  tie  the  threads  of  the  same  colour 
in  a double  knot,  possible ; or,  should  this  be  too  difficult,  by  a single 
knot,  which  is  prevented  from  being  loosened  by  twisting  the  two 
ends  of  the  threads  nearly  up  to  the  suture,  and  securing  them 
both  with  a little  common  wax,  or  sealing  wax  softened  by  heat.  If 
nothing  interferes  with  the  progress  of  the  agglutination,  it  may  be 
completed  on  the  fourth  or  fifth  day ; but  unless  something  occurs  to 
make  it  necessary,  it  is  better  not  to  examine  the  parts  with  the 
speculum  earlier  than  the  eighth  day,  and  even  then  it  must  be  done 
with  the  utmost  care,  and  with  a small  speculum  having  a large  open- 
ing in  the  direction  of  its  long  diameter.  In  order  still  more  to  avoid 
every  kind  of  stretching,  we  should  endeavour  to  explore  the  wound 
with  the  rectum-speculum,  or  by  merely  separating  the  vaginal  pari- 
etes  with  the  fingers.  Should  we  be  in  too  much  haste  to  ascertain 
the  condition  of  the  parts,  the  success  of  the  operation  might  be  com- 
promised, as  indeed  has  sometimes  happened,  particularly  after  the 
use  of  the  cautery;  on  the  eighth  day,  the  ligatures  at  the  angles  of 
the  wound  may  be  removed,  and  two  or  three  days  later,  the  others. 
Generally,  three  ligatures  suffice  for  the  largest  fistulas;  very  rarely 
more  than  four  are  applied ; long  scissors,  with  very  narrow  blades, 
and  blunt  points,  serve  to  cut  the  threads,  and  to  secure  them,  they 


Fig.  34. 


VAGINAL  FISTULAS. 


257 


are  to  be  seized  with  a pair  of  forceps,  which  may  usually  be  done 
with  great  facility. 

The  method  we  have  just  described  for  the  relief  of  transverse  and 
oblique  fistulas,  in  which  cauterization  would  have  failed,  is  equally 
applicable  to  longitudinal  fistulas,  provided,  to  unite  their  edges,  we 
employ  the  interrupted,  in  preference  to  the  whip  suture  by  means 
of  our  spiral  needle. 

We  think  we  may  affirm  that  the  instruments  and  modifications 
proposed  by  us  have  the  advantage  of  rendering  the  renewal  and 
reunion  of  the  edges  of  all  vagino-vesical  fistulas,  easier,  quicker,  and 
always  practicable?  be  their  form,  extent  and  situation  what  it  may. 
Indeed ; 

1.  The  renewal  of  the  edges  of  transverse  and  oblique  fistulas, 
which  is  the  most  tedious  and  difficult  part  of  the  operation,  is  easily 
and  rapidly  accomplished,  either  by  means  of  our  double-edged  knife 
with  vertical  blade,  which  takes  any  desirable  direction,  or  with  our 
cutting  forceps,  whose  movable  blades  are  so  arranged  as  to  cut 
either  from  behind  forwards,  from  before  backwards,  from  right  to 
left,  or  obliquely. 

2.  The  union  of  the  edges  is  effected  with  equal  facility,  in  longi- 
tudinal fistula,  by  our  spiral  needle,  and  with  our  two  needles  with 
curved  shanks  and  handles,  terminated  by  a small  spear-point,  which 
may  be  placed  in  the  edges  of  any  vaginal  fistula,  whatever  be  its 
direction. 

3.  Our  forceps,  designed  to  sustain  the  edges  of  the  wound  during 
their  removal  by  the  cutting  instrument,  and  perforation  by  the  nee- 
dles, are  applicable  in  every  direction,  and  are  especially  adapted  for 
seizing  the  anterior  lip  of  transverse  and  oblique  fistulas,  which  it  is 
impossible  to  do  with  any  other  forceps.  We  may  add,  that  our 
bent  and  movable  cautery  and  our  caustic  holder,  of  the  same  shape, 
render  the  cauterization  by  which  we  should  always  commence  the 
treatment  of  vaginal  fistulas  communicating  with  the  bladder  or 
rectum,  both  easier  and  more  commodious. 

OF  THE  APPROXIMATION  OF  THE  EDGES  OF  VAGINO-VESICAL  FIS- 

TULAS  BY  MEANS  OF  PECULIAR  INSTRUMENTS,  WITHOUT  THE 

USE  OF  THE  SUTURE. 

In  1826,  Professor  Lallemand,  wishing  to  combine  immediate 
union  of  the  wound  with  previous  cauterization  of  its  edges,  resorted 
to  the  following  method  : 

In  the  first  place,  he  cauterized  with  lunar  caustic  fixed  in  a 
ring  carried  upon  the  index  finger  until  the  lips  of  the  fistula  were 
moderately  inflamed;  he  then  introduced  into  the  bladder  through  the 
urethra,  a silver  catheter,  called  a hooked  catheter,  ( sonde  airigne ,) 
the  object  of  which  is  to  procure  a constant  flow  of  urine,  and  which 
contains  in  its  cavity  curved  hooks  moved  by  a screw  also  placed  in 
the  interior  of  the  instrument,  in  such  a way  as  to  project  through  the 
eyes  of  the  instrument  at  will,  and  to  become  attached  to  the  poste- 
rior lip  of  the  fistula  about  six  lines  beyond  its  edge.  A finger  car- 
17 


258 


VAGINAL  FISTULAS. 


ried  into  the  vagina,  sustains  the  anterior  paries  of  that  canal,  pre- 
vents its  yielding,  and  facilitates  the  insertion  of  the  hooks.  When 
these  have  firmly  seized  the  vesico-vaginal  septum,  a silver  plate, 
which  has  been  until  then  retained  in  the  anterior  extremity  of  the 
instrument,  is  pushed  towards  the  beak  of  the  catheter  by  a spring 
with  a button-end,  and  left  to  itself.  A thick  layer  of  eharpie, 
placed  in  front  of  the  urinary  meatus,  receives  the  pressure  of  the 
plate  which  forces  the  canal  of  the  urethra  and  the  anterior  edge  of 
the  fistula  backwards,  whilst  the  posterior  lip  is  drawn  forwards 
by  the  hooks  of  which  we  have  spoken.  The  learned  and  ingenious 
author  of  this  method  and  apparatus  has  published  a case  of  chronic 
vesico-vaginal  fistula  cured  by  its  application ; nut  it  would  seem 
from  Professor  Velpeau*  that  the  success  was  not  permanent,  and 
that  in  that  patient,  as  well  as  several  others  treated  in  the  same  way, 
the  infirmity  returned  just  as  before  the  operation.  We  cannot 
moreover  determine  any  thing  from  the  satisfactory  results  which 
were  at  first  obtained  ; for  as  the  operation  had  been  commenced  and 
terminated  by  cauterization,  it  might  very  well  be  that  the  first  suc- 
cesses were  owing  to  this  means  which  already  numbers  a good  many 
examples  of  complete  cure.  We  add,  moreover,  that  other  attempts, 
made  with  the  apparatus  of  M.  Lallemand,  as  well  as  that  we  wit- 
nessed in  1829,  at  the  hospital  of  Beaujon,  did  not  yield  the  good 
results  at  first  looked  for. 

The  illustrious  Dupuytren  successfully  used  an  instrument,  con- 
sisting of  a large  female  catheter,  which  has  upon  its  sides  two  leaves, 
opening  like  wings  or  shutting  up  closely,  according  as  we  withdraw  or 
push  forwards  a central  movable  stilet,  intended  to  move  them.  After 
the  closed  instrument  has  been  passed  into  the  bladder,  we  open  and 
fix  the  movable  leaves  by  means  of  the  central  stilet,  and  then  draw 
it  towards  us  as  though  we  designed  to  remove  it  while  arranged  in 
this  manner.  The  leaves  remaining  separated,  prevent  the  catheter 
from  engaging  in  the  urethra,  but  they  drag  forwards  the  posterior 
lip  of  the  fistula,  at  the  same  time  that  the  urethra  and  anterior  lip 
are  forced  backwards  by  means  of  a tampon  of  eharpie  or  linen, 
placed  between  the  urinary  meatus  and  the  external  portion  of  the 
instrument.  This  process,  which  possesses  the  advantage  of  perforat- 
ing neither  the  vagina  nor  the  bladder,  seems  to  us  to  be  incapable  of 
effecting  the  complete  approximation  of  the  edges,  and  it  is  probable 
that  the  successes  which  have  followed  its  employment  are  due  to  the 
cauterization,  to  which  it  may  become,. however,  an  useful  accessory. 

M.  Laugier  invented  a hooked  forceps,  intended  to  approximate 
the  edges  of  fistulas,  which,  unlike  M.  Lallemand’s,  acts  from  the 
vagina  towards  the  bladder,  by  changing  the  direction  of  its  hooks, 
according  as  the  perforation  is  transverse  or  longitudinal.  In  the 
former  case,  the  hook-forceps  presents  two  parallel  blades  which 
glide  upon  each  other,  or  separate  at  will,  and  are  terminated  at 
their  holding  extremities  by  a double  hook  intended  to  be  fastened 
in  the  anterior  and  posterior  edges  of  the  fistula.  After  the  parts  are 
seized,  a simple  contrivance  brings  the  hooks  together  so  as  to  ap- 


Medecine  Operatoire,  t.  iii.  p.  654. 


VAGINAL  FISTULAS. 


259 


proximate  the  edges.  In  longitudinal  fistulas,  it  is  necessary  that  the 
hooks  on  each  claw  should  be  parallel  to  the  axis  of  the  body,  and 
the  extremity  that  supports  them,  bent  upon  the  edge : lastly,  the 
forceps  should  have  the  blades  more  or  less  curved,  where  the  fis- 
tula is  oblique.  When  the  coaptation  is  effected,  the  whole  is  main- 
tained in  place  by  means  of  charpie,  placed  in  the  anterior  part  of 
the  vagina.  The  method  of  M.  Laugier,  which  we  have  been  told 
was  lately  employed  unsuccessfully  by  himself,  has  inconveniences 
like  the  others,  which  have  been  pointed  out  by  M.  Velpeau, 
and  which  we  refrain  from  mentioning  here,  lest  we  should  extend 
our  remarks  too  far.  It  is  for  the  same  reason,  that  we  avoid  de- 
scribing the  method  and  instruments  proposed  by  Doctor  Dufresne 
Chassagne,  in  a thesis  defended  by  him  before  the  faculty  of  medi- 
cine of  Paris,  on  the  30th  January,  1834,  and  which  may  be  con- 
sulted with  advantage. 

It  now  remains  for  us  to  speak  of  the  instruments  invented  by  M. 
Recamier,  which  were  exhibited  to  us  by  that  celebrated  and  dexte- 
rous practitioner.  One  of  them,  intended  for  reviving  the  edges  of 
the  fistula,  has  two  stenjs  which  slide  upon  each  other.  The  larger 
of  these  stems,  hollow  in  its  whole  length,  is  terminated  at  its  vesi- 
cal extremity  by  a small  square  plate,  and  is  bent  above  at  a 
right  angle,  so  as  to  rest  against  one  of  the  lips  of  the  vagino- 
vesical perforation,  and  revive  it  by  an  incision  made  with  a small 
cutting  blade  placed  at  the  end  of  the  solid  stem,  sliding  in  the 
first.  Another  instrument,  differing  slightly  from  this,  is  employed 
for  the  renewal  of  the  other  edge.  When  this  first  step  of  the  ope- 
ration is  finished,  a kind  of  small  steel  forceps,  terminated  by  several 
claws  of  silver,  is  intended  to  unite  the  edges  of  the  fistula,  by  the 
approximation  of  the  two  blades  of  the  instrument.  Though  these 
different  methods  proposed  by  M.  Recamier  are  very  ingenious,  we 
think  that,  having  been  made  for  a particular  case  of  longitudinal 
fivStula,  they  would  require  several  modifications  to  become  appli- 
cable in  cases  of  oblique  and  transverse  perforations. 

We  shall  conclude  our  remarks  on  the  treatment  of 
vagino-vesical  fistula  by  saying,  that  the  hooks  which  Fig.  35. 
are  applied  with  difficulty  in  longitudinal  fistulas,  might 
be  substituted  by  a spiral  needle  like  that  we  have 
already  spoken  of,  with  this  difference,  however,  that 
it  should  have  no  groove,  and  must  be  made  according 
to  the  size  of  the  perforation,  so  that  when  once  applied, 
it  may  remain  untouched  and  preserve  the  edges  of  the 
wound  united  much  better  than  any  of  the  catheters  or 
hook-forceps.  The  spear-point  which  terminates  the 
•needle,  should  be  removed  when  it  is  fixed  in  the  va- 
gino-vesical septum ; and  when  the  operator  supposes 
the  consolidation  to  be  complete,  he  readjusts  the  handle 
which  had  also  been  withdrawn  and  had  served  to  fix 
the  instrument ; he  then  disengages  the  needle  properly 
so  called,  by  unscrewing  it,  and  by  following  a direction 
the  reverse  of  that  which  he  had  used  for  its  appli- 
cation to  the  edges  of  the  fistula. 


260 


VAGINAL  FISTULAS. 


Whatever  be  the  method  used  in  the  treatment  of  these  cases, 
a catheter  must  be  kept  in  the  bladder,  and  abdominal  compression, 
suitable  position,  and,  in  fine,  whatever  can  serve  to  favour  the 
coaptation  of  the  parts,  and  the  escape  of  the  urine  through  the 
canal  of  the  urethra,  must  also  be  attended  to. 

We  have  still  to  refer  to  a method  which  M.  J.  Jobert  de  Lam- 
balle  appears  to  have  used  successfully,  videl.  the  closure  of  a shal- 
low fistula  in  the  vagina  by  means  of  a flap  taken  from  the  inner 
surface  of  one  of  the  labia  externa  by  careful  dissection,  then  car- 
ried from  before  backwards  and  maintained  upon  the  anormal  per- 
foration, with  suture  points. 

Seeing  that  almost  all  the  surgical  means  for  the 
Fig.  36.  treatment  of  vagino-vesical  fistula  failed,  one  of  the  most 
distinguished  of  our  young  practitioners,  M.  Vidal  de 
Cassis,  conceived  the  idea  of  obliterating  the  vagina,  so 
as  to  make  it  an  appendage  to  the  bladder,  and  a sort 
of  bas-fond  for  this  organ.  This  method,  which  was 
employed  by  its  author,  on  the  5th  July,  1834,  at  the 
venereal  hospital,  upon  a female  whose  vagino-vesical 
septum  was  largely  perforated,  with  great  loss  of  sub- 
stance, is  executed  by  means  of  two  strong  straight 

!|j  needles  mounted  upon  small  ebony  handles,  whose  per- 
il forating  end  arranged  in  the  form  of  a spear-point,  has  an 
1 eye  in  the  centre  large  enough  to  receive  a double  liga- 
II  ture.  After  having  freshened  the  whole  circumference  of 
11  the  vaginal  orifice,  one  of  the  needles  is  inserted  a little 

|j  within  the  right  nympha  three  lines  from  the  bleeding 

® surface,  and  as  soon  as  the  spear-point  projects  into  the 
vagina,  the  loop  of  the  double  ligature  is  seized  with  a 
pair  of  dissecting  forceps  which  should  be  held  by  an  aid,  while  the 
needle  is  withdrawn  by  the  same  route  that  it  was  introduced. 
Then  the  other  needle  is  inserted  in  the  same  way  as  the  first,  but 
upon  the  opposite  side,  and  a little  within  the  left  nympha,  after  which 
the  ligature,  having  been  seized  as  the  first  was,  the  instrument  is 
withdrawn,  deprived  of  its  ligature  as  upon  the  right  side. 

After  the  needles  have  been  removed,  the  two  loops  of  thread  re- 
main at  the  orifice  of  the  vagina;  the  left  loop  should, be  passed 
through  the  right,  so  that  by  drawing  down  the  two  threads  forming 
the  latter,  we  shall  bring  along  with  them  the  threads  which  form 
the  other  one.  It  follows  from  this  that  the  double  ligattire  of  the 
right  feide  is  drawn  completely  away,  whilst  the  double  thread  of  the 
left  side  follows  the  route  which  the  two  needles  pursued,  in  order 
that  it  alone  may  effect  the  reunion  of  the  two  edges  of  the  wound. 
If  we  wish  to  employ  the  quill  suture,  it  is  only  necessary  to  sepa- 
rate the  two  threads  and  interpose  between  them  a piece  of  catheter 
or  the  end  of  a quill ; if  the  simple  suture  should  be  preferred,  we 
have  merely  to  cross  the  threads  and  tie  them. 

The  vaginal  obliteration  attempted  by  M.  Vidal,  in  the  mode  just 
described,  was  not  followed  by  entire  success.  The  union  of  the 


RECTO-VAGINAL  FISTULAS. 


261 


parts  became  quite  established,  cicatrization  was  rapidly  advancing, 
the  urine  escaped  wholly  by  the  catheter  introduced  into  the  bladder, 
and  every  thing  promised  success,  when  the  resident  physician  at- 
tached to  M.  Vidal’s  wards,  broke  open  the  nearly  complete  cica- 
trix, because  the  patient  complained  of  pain  above  the  vaginal 
obturation.  It  is  unfortunate  that  this  attempt,  as  novel  as  it  was 
ingenious,  was  not  followed  by  the  result  which  every  thing  at  first 
gave  reason  to  hope  for. 

We  fear  that  the  closure  of  the  vagina,  proposed  by  M.  Vidal, 
though  its  object  be  to  remedy  a disgusting  infirmity,  which  is  gene- 
rally beyond  the  resources  of  our  art,  can  rarely  be  employed,  because, 
even  supposing  that  no  objection  could  be  made  to  it  on  account  of 
the  injurious  action  which  the  urine  would  probably  exert  on  the 
walls  of  the  vagina,  it  would  still  have  the  inconvenience  of  pre- 
venting the  flow  of  the  menses  which  could  take  place  only  through 
the  urinary  meatus,  and  besides,  it  would  be  a positive  obstacle  to  a 
sexual  intercourse.  If  the  method  were  essayed  only  upon  women 
of  advanced  age,  most  of  these  objections  would  no  longer  hold, 
and  the  chances  of  success  would  be  much  greater.  However,  the 
suture  applied  in  the  mode  just  described  is  extremely  simple  and 
easy ; we  regard  it  as  highly  advantageous  for  the  reunion  of  very 
thick  tissues  presenting  broad  surfaces,  as  happens  in  suture  of 
the  perineum,  which  has  been  successfully  performed  twice  by  M. 
Vidal. 

OF  RECTO-VAGINAL  FISTULAS. 

By  recto-vaginal  fistulas,  are  meant  perforations  that  open  a com- 
munication through  the  posterior  wall  of  the  vagina,  and  the  anterior 
wall  of  the  rectum. 

These  fistulas,  which  are  generally  longitudinal,  are  mostly  the 
result  of  lacerations  produced  during  labour,  either  by  the  head  of 
the  child  or  by  the  blades  of  the  forceps.  They  may  also  be  caused 
by  cancerous  or  syphilitic  ulcerations  of  the  recto-vaginal  septum ; 
by  the  presence  of  a lipoma  or  any  other  tumour  which  has  become 
inflamed  and  produced  an  abscess  communicating  with  the  rectum ; 
finally,  they  may  be  produced  by  angular  bodies  introduced  acci- 
dentally into  the  rectum  or  vagina,  and  especially  by  the  action  of 
pessaries  on  the  posterior  wall  of  that  canal. 

Several  authentic  cases  go  to  prove  that  communications  be- 
tween the  vagina  and  the  rectum  may  be  congenital;  Barbaut* 
and  Professor  Orfila,t  cite  examples  of  the  kind.  The  celebrated 
Dupuytrenf  refers  to  a case  observed  by  M.  Lepine,  who  saw  a 
little  girl  six  days  old,  in  whom  the  vagina  gave  issue  to  portions 
of  meconium ; the  child  exhibited  all  the  symptoms  produced  by 
retention  of  foecal  matter,  and  the  recto-vaginal  fistula  had  begun  to 
be  formed  but  a short  time  before,  as  there  was  no  sulcus  between 
the  thighs. 

* Cours  d’accouchement,  p.  59.  t Medecine  legale,  tom.  i.  p.  150. 

% Dicdonnaire  de  Medecine  et  de  Chirurg.  prat.  t.  iii.  p.  121. 


262 


RE  CTO- VAGINAL  FISTULAS. 


A surgeon  attempted  to  discover  the  anus,  and  made  an  incision 
through  the  integument  of  the  perineum,  between  the  point  of  the 
coccyx  and  the  posterior  commissure  of  the  vulva.  This  incision  dis- 
closed a fluctuating  tumour,  formed  of  intestine,  which  was  seen  be- 
tween the  edges  of  the  wound.  An  opening  made  in  the  lower  part 
of  the  tumour  gave  issue  to  a large  quantity  of  gas  and  meconium ; 
the  recto -vaginal  fistula  closed  entirely,  and  the  child  perished  three 
years  after  of  a disease  which  had  no  connection  with  its  congenital 
defect. 

Dr.  Ricord,*  surgeon  to  the  venereal  hospital,  reports  the  case  of 
a woman  twenty-two  years  of  age,  large,  strong,  and  in  good 
health,  who  is  without  an  anus,  and  in  whom  the  stercoraceous  mat- 
ter is  voluntarily  expelled  through  a recto-vaginal  opening  or  rather 
passage. 

It  is  probable,  says  M.  Guerbois,t  who  also  mentions  these  cases, 
that  in  this  woman  the  recto-vaginal  opening  is  provided  with  sphinc- 
ters to  prevent  the  involuntary  escape  of  the  stercoraceous  matter, 
which  would  prove  that  nature,  even  in  her  deviations,  always  tends 
to  diminish  the  sufferings  and  accidents  to  which  the  human  spe- 
cies is  exposed. 

Perforations  of  the  recto-vaginal  septum,  with  loss  of  substance, 
give  issue  to  the  fluid  portions  of  the  faecal  matter,  and  intestinal  gases, 
which  latter  escaping  involuntarily  through  the  fistula,  pass  out  by 
the  vulva,  whilst  the  solid  portions  are  expelled  in  part  through  the 
vagina,  and  in  part  through  the  anus,  but  only  during  defecation. 

Recto-vaginal  tend  more  to  spontaneous  cure  than  vesico-vaginal 
fistulas,  and  for  this  reason  it  is  that  they  have  attracted  the  atten- 
tion of  the  profession  even  less  than  the  latter.  When  recent,  they 
not  unfrequently  close  of  themselves,  especially  when  aided  by  ab- 
solute rest,  by  position  upon  the  side,  emollient  lotions,  mucilagi- 
nous and  anodyne  enemata,  severe  regimen,  and  attention  to  clean- 
liness. F.  Ruysch,±  who  died  in  1731,  has  recorded  a case  of 
spontaneous  cure  of  a large  recto-vaginal  fistula.  Sedillot  and  M. 
Philippe  de  Mortagne§  have  published  some  nearly  similar  cases ; 
Professor  Velpeau  also  mentions  a young  woman  in  his  wards,  at  La 
Pitie,  who  in  a single  fortnight  was  cured  by  injections  of  red  wine, 
of  a recto-vaginal  fistula  which  had  lasted  eight  months ; finally, 
M.  Deschamps,||  at  that  time  resident  physician  at  the  hospital  Co- 
chin, cites  an  example  of  this  kind  met  with  in  a female  sixty- 
eight  years  of  age,  who  died  at  the  hospital  La  Salpetriere,  in  1833. 
Unfortunately,  as  M.  Velpeau  says,  the  organism  does  not  always 
respond  to  the  wishes  of  the  physician,  and  perforations  of  the 
vesico-vaginal  septum  persist  in  spite  of  the  best-directed  medical 
treatment : we  are  then  compelled  to  resort  to  the  employment 
of  the  means  already  proposed  for  vesico-vaginal  fistula  ; for  exam- 

* Journal  hebdom.  de  M6d.  t.  xiii 

| These  de  concours  pour  une  chaire  de  clinique  Chirurg.,  p.  20,  1834. 

i 59th  case. 

§ Velpeau  Medecine  operatoire,  tom.  iii.  p.  663. 

11  Guerbois,  These  de  concours,  Juillet,  1834,  p.  20. 


RECTO-VAGINAL  FISTULAS. 


26  3 


pie,  to  cauterization,  to  the  suture,  or  the  approximation  of  the  edges 
by  means  of  various  instruments. 

When  the  fistula  is  small,  cauterization,  with  the  nitrate  of  silver, 
in  the  manner  we  described  while  treating  of  vesico-vaginal  fis- 
tulas, ought  generally  to  be  made  use  of  first ; if  large,  on  the  con- 
trary, this  method,  which  would  offer  scarcely  any  chance  of  suc- 
cess, especially  if  employed  alone,  should  be  rejected  j and  it  then 
becomes  necessary  to  resort  to  the  employment  of  the  suture,  chiefly 
the  whip  suture,  made  with  the  spiral  needle  described  while  speak- 
ing of  antero-posterior  fistulas  of  the  vagino-vesical  septum.  Before 
attempting  the  operation  the  patient  should  be  prepared  for  it  several 
days  beforehand,  by  the  use  of  gentle  laxatives,  and  particularly  by 
frequent  suppositories  of  beurre  de  cacao,  in  order  to  keep  the 
bowels  soluble  and  diminish  the  contraction  of  the  sphincter  ani, 
which  often  necessitates  efforts  for  the  expulsion  of  the  faecal  matter 
capable  of  tearing  the  suture. 

In  a case  of  very  narrow,  recto-vaginal  fistula,  the  elder  Cullerier,  on 
one  occasion,  successfully  employed  compression  by  means  of  a couple 
of  plates,  one  of  which  was  introduced  into  the  anus,  and  the  other 
into  the  vulva;  we  ought  to  mention  that  this  method  has  been  used 
several  times  by  the  younger  Cullerier,  and  that  that  able  practitioner 
was  obliged  to  renounce  it,  on  account  of  the  numerous  accidents 
which  it  occasioned.  Finally,  \ve  must  speak  of  a method  which 
consists  in  treating  fistulas  that  open  into  the  vagina  very  near  the 
vulva  by  incision,  as  though  they  were  cases  of  fistula-in-ano.  This 
method,  recommended  by  M.  Velpeau,  has  been  several  times  used 
with  success  by  that  practitioner,  and  once  by  us  in  the  month  of 
May,  1835,  in  the  case  of  a female  twenty-nine  years  of  age,  a wine- 
dealer  in  the  rue  du  Cherche  Midi. 

We  shall  conclude  with  the  remark,  that  double  fistula,  which  is  most 
frequently  caused  by  the  presence  of  a pessary  in  the  vagina,  seldom 
requires  any  thing  more  than  attention  to  cleanliness.  We  ought  rarely 
to  resort  to  operations  in  such  cases,  which  should  be  performed, 
moreover,  if  at  all,  one  after  the  other ; that  is  to  say,  we  should  not 
seek  to  close  the  recto-vaginal  fistula,  until  that  of  the  vesico-vaginal 
septum  is  entirely  cured.  We  may  add,  that  in  cases  where  there  is 
some  reason  to  suppose  the  affection  to  depend  upon  venereal  dis- 
ease, we  should  make  use  of  a specific  treatment,  both  general  and 
local,  as  we  should  likewise  confine  ourselves  to  a palliative  treat- 
ment where  the  perforation  has  been  produced  by  cancer  of  the  neck 
of  the  womb. 

[A  most  ingenious  and'  successful  treatment  of  recto-vaginal  fistula  is  that 
invented  and  practised  by  that  able  and  well-known  surgeon,  Dr.  J.  Rhea 
Barton,  of  this  city,  who  gave  an  account  of  it  in  the  American  Journal  of 
the  Medical  Sciences,  under  date,  Philadelphia , June , 1840.  This  most 
interesting  case  is  republished  here  from  the  original,  in  Hays’  Journal,  (loc. 
cit.)  and  is  republished,  both  on  account  of  the  intrinsic  interest  of  the  case, 
and  for  the  purpose  of  extending  still  further  the  correction  of  an  act  of  edi- 


264 


RECTO-VAGINAL  FISTULAS. 


torial  injustice  in  relation  to  it.  The  case  may  be  found  in  Dr.  Hays’  Jour- 
nal, for  August,  1840,  at  p.  305.  It  is  the  second  article  of  that  number, 
and  is  headed 

A RECTO-VAGINAL  FISTULA,  CURED  BY  J.  RHEA  BARTON,  M.  D. 

Miss  R — , of  Virginia,  an  unmarried  lady,  aged  twenty-two,  most  respect- 
ably connected  in  Philadelphia,  shortly  after  her  return  from  a visit  to  this 
city,  in  June,  1835,  experienced  all  the  symptoms  of  an  acute  abscess  in 
the  region  of  the  rectum  and  vagina.  It  formed,  and  broke  on  one  side, 
and  was  lanced  on  the  other.  After  a copious  discharge  of  its  contents,  one 
of  the  openings  healed,  whilst  the  other  became  fistulous,  and  remained  so 
most  obstinately  for  the  period  of  about  four  years ; resisting  both  general 
and  local  treatment,  including  injections,  tents,  setons,  caustic,  incisions  and 
excisions.  She  came  to  Philadelphia  for  further  treatment,  and  in  March, 
1839,  was  placed  under  my  care. 

“ The  fistula  was  found  commencing  about  three-fourths  of  an  inch 
within  the  labium  of  the  right  side,  thence  passing  by  a very  irregular 
course,  up  the  pelvis,  and  inclining  towards  the  rectum,  into  which  cavity  it 
finally  opened,  about  three  and  a half  or  four  inches  from  its  inferior  aperture 
in  the  vagina.  Through  this  sinus  there  issued  fluids  insufficient  quantity  to 
keep  the  genitals  continually  moist.  Flatus,  also,  at  times,  found  its  way 
through  this  channel. 

“ The  discovery  of  the  real  nature,  and  the  extent  of  this  sinus,  passing 
as  it  did  from  one  to  another  important  cavity,  and  establishing  a communi- 
cation between  them,  presented  an  embarrassing  view  of  the  case,  as  to  the 
mode  of  cure.  It  was  now  clear  that  the  case  must  be  treated  with  refer- 
ence to  its  connection  with  the  rectum,  and  upon  the  same  principles  that 
govern  us  in  the  cure  of  fistula-in-ano  ; for,  in  fact,  it  was  virtually  such  a 
case  modified  by  the  unfortunate  implication  of  the  vagina. 

“ It  was  nevertheless  apparent  that  this  sinus  could  not  be  included  in  a 
seton  and  ulcerated  through,  nor  be  laid  open,  as  is  usually  done  in  the 
common  fistula-in-ano,  without  destroying  the  perineum,  and  laying  these 
two  great  cavities  into  one  ! thereby  causing  a more  unhappy  state  of  the 
parts  than  had  previously  existed.  The  duty,  therefore,  of  the  surgeon  was 
very  clear,  either  to  consign  the  patient  to  a continuation  of  her  loathsome 
complaint,  or  to  adapt  an  operation  to  her  peculiar  case.  The  latter  was 
successfully  done,  as  follows. 

“ A fine  tent  was  inserted,  for  a few  days,  to  dilate  the  sinus,  and  to  render 
its  course  less  tortuous.  A seton  was  then  introduced,  with  an  eyed  probe, 
into  the  sinus  per  vaginam,  and  passed  through  its  whole  extent  until  it  had 
penetrated  the  rectum,  by  the  orifice  into  that  cavity.  It  was  then  brought 
down  and  out  per  anum.  The  two  ends  were  then  loosely  tied  together, 
merely  for  security  against  its  slipping  out.  After  a few  days  the  loop  was 
opened,  and  the  end  of  the  seton  passing  out  of  the  vagina  was  put  through 


RECTO-VAGINAL  FISTULAS, 


265 


the  eye  of  a probe,  which  was  previously  crooked  at  the  other  end.  This 
probe  was  then  inserted  into  the  orifice  of  the  vagina  ; thence  about  an  inch 
and  a half  up  the  sinus  ; then  its  point  was  directed  toward  the  perineum,  just 
exterior  to  the  sphincter  ani  muscle.  Here  a small  but  somewhat  deep  inci- 
sion was  made,  and  the  probe  pushed  through  it,  bringing  along  with  it  the 
end  of  the  seton  which  had  been  doubled  upon  itself.  Theseton  now,  instead 
of  passing  out  of  the  vagina,  as  at  first,  after  coming  down  from  the  bowel 
through  only  part  of  the  sinus,  descended  through  the  new  channel  I had 
made  for  it.  The  ends  lying  almost  side  by  side,  were  now  tied  together, 
thus  forming  a loop,  in  which  were  included  the  parts  between  the  outer 
surface  of  the  sphincter  ani  muscle  and  the  rectum.  This  seton  or  ligature 
was  subsequently  drawn  or  twisted  tighter  and  tighter  from  time  to  time,  in 
order  to  cause  its  ulceration  through  the  included  parts,  as  we  do  in  com- 
mon fistula-in-ano,  when  operating  by  the  ligature  or  wire.  So  soon  as  by 
these  means,  the  new  and  direct  channel  was  formed,  and  had  attained  a 
larger  size  than  that  penetrating  the  vagina,  the  discharges  from  the  rectum 
deserted  that  portion  of  the  route  which  led  into  the  vagina,  and  took  the 
course  of  the  seton.  This  was  exactly  the  end  I designed  to  accomplish  by 
my  operation ; believing  that,  if  I could  establish  a freer  and  more  direct 
passage  for  the  escape  of  the  fluids  of  the  rectum  than  that  per  vaginam , the 
sinus  opening  into  this  cavity  would  heal  sua  sponte , and  become  perma- 
nently obliterated.  My  opinions  were  confirmed,  for  long  before  the  seton 
had  made  its  way  out  by  ulceration,  the  vaginal  portion  of  the  sinus  had 
healed,  and  the  integrity  of  this  organ  had  been  restored.  I had  now  only 
to  pursue  the  treatment  of  this  case  as  I should  have  done,  had  it  been  a 
simple  case  of  fistula-in-ano — namely,  by  continuing  to  tighten  the  ligature 
every  day  or  two,  until  it  finally  came  so  near  away,  that  a slight  clip  by  the 
scissors  divided  the  insignificant  intervening  portion  yet  retaining  it  when  it 
was  released.  These  parts  healed  up  in  a few  days. 

“ I had  now  the  satisfaction  of  finding  that  my  treatment  of  the  patient 
was  completely  successful.  She  was  entirely  cured,  and  without  disfigure- 
ment of  a recto-vaginal  fistula,  existing  at  an  interesting  period  of  her  life, 
and  under  circumstances  and  embarrassments  rarely  to  be  met  with  in  the 
same  case. 

“It  is  now  nearly  one  year  since  my  patient  was  discharged  cured,  and 
recent  accounts  from  her  announce  her  to  be  in  perfect  health. 

“ Philadelphia , June,  1840.” 

The  lady  was  in  Philadelphia  within  a short  time  past,  (August,  1844,) 
and  continues  to  be  perfectly  free  from  her  complaint,  now  full  four  years 
since  the  operation. 

Nothing  could  be  more  ingenious  in  the  devising,  nor  successful  in  the 
application,  than  this  new  triumph  of  the  skill  of  the  surgeon,  and  it  is  just 
that,  whatever  praise  ought  to  be  meted  out  to  those  who  make  great  im- 
provements in  important  affairs,  should  be  duly  paid.  There  is  reason  to 


266 


RECTO-VAGINAL  FISTULAS. 


believe  that  full  justice  is  not  done  to  Dr.  Barton  for  this  operation,  in  con- 
sequence of  some  mistake  of  the  Gazette  Medicate  of  Paris,  in  the  number 
for  Saturday,  May  1,  1841.  In  that  number,  p.  283,  is  stated,  an  Obser- 
vation de  Fistule  recto-perineale ; (Yaginale)  eommuniquee  par  M.  le  Docteur 
Valentine  Mott. 

M.  Guerin,  the  editor  of  the  Gazette , gives  a translation  of  Dr.  Barton’s 
account  of  his  beautiful  process,  as  that  of  Miss  R — , of  Virginia,  aged 
twenty-two,  &c.,  but  he  adds,  that  shortly  after  a journey  from  Philadelphia 
to  New  York,  she  experienced  the  symptoms  of  an  abscess,  &c.  &c.,  after 
which  the  case  is  given  in  full,  as  we  have  just  copied  it.  The  unfortunate 
mistake  consists  in  adding  the  word  New  York  to  the  translation.  No  such 
word  was  to  be  found  in  Dr.  Barton’s  statement,  and  they  do  him  the  addi- 
tional injustice  of  wholly  leaving  out  his  name  at  the  head  of  the  article,  and 
indeed  no  allusion  is  made  to  him  throughout  the  entire  French  publication 
of  his  paper,  nor  the  least  regard  paid  to  his  date,  of  “ Philadelphia,  June, 
1840,”  at  the  foot  of  his  statement.  By  the  appearance  of  Dr.  Mott’s  name 
as  the  communicator,  and  the  introduction  of  the  word  New  York  in  the 
translation,  the  learned  world  suppose  Dr.  Mott  to  be  the  operator  and 
inventor  of  the  operation,  and  he  was  accordingly  complimented  for  it  by 
the  Provincial  Medical  Journal,  the  London  Medical  Gazette,  and  others,  as 
its  author.  This  was  the  result  of  some  want  of  care  or  precision  in  the 
translation  of  the  paper  of  Dr.  Barton,  who  gave  it  to  Dr.  Mott,  whilst  in 
Paris,  in  1841,  that  sur'geon  being  desirous  to  cause  its  publication  in 
^ Paris  Journal.  Dr.  Mott’s  note  to  Dr.  Guerin,  accompanying  Dr.  Barton’s 
paper,  and  complimenting  him  (Dr.  B.)  for  his  operation,  shows  that  the 
mistake  was  not  chargeable  to  Dr.  M.,  but  it  is  presumable  that  Dr.  Guerin’s 
Journal,  having  given  accidentally  the  meed  to  the  New  York  surgeon,  our 
townsman  must  submit  to  a temporory  stasis  in  some  parts  of  Europe  at 
least,  of  the  reputation  which  his  other  great  operations  have  acquired  for 
him,  and  which  would  have  been  as  greatly  increased  as  this  success  de- 
served that  it  should  be,  had  it  not  been  for  this  unfortunate  mistake.  The 
readers  of  M.  Colombat’s  article  on  recto-vaginal  fistula  at  least  will  learn 
the  value  and  the  author  of  the  operation. — M.] 

OF  FOREIGN  BODIES  ACCIDENTALLY  INTRODUCED  INTO  THE  VAGINA, 
THE  UTERUS  AND  THE  CANAL  OF  THE  URETHRA. 

Of  all  the  cavities  lined  by  mucous  membrane,  the  vagina  is  the 
one  in  which  we  most  frequently  meet  with  foreign  bodies,  which 
have  been  introduced  either  with  a therapeutical  view,  with  criminal 
intentions,  or  to  satisfy  a childish  curiosity. 

Notwithstanding  its  size  and  direction,  the  vulvo-uterine  canal 
readily  retains  bodies  which  have  passed  its  orifice,  because  of  the 
great  number  of  its  transverse  folds  which  are  found,  especially  at  the 
inferior  portion  of  its  cavity. 

The  presence  of  a foreign  body  in  the  vagina,  gives  rise  to  inilam- 


FOREIGN  BODIES  IN  THE  VAGINA. 


26  7 


mation  more  or  less  violent  according  to  its  nature,  and  at  the  same 
time  occasions  a number  of  symptoms,  such  as  severe  pain,  ulcer- 
ation, ichorous  and  very  fetid  discharges,  perforations,  dysuria,  hectic 
fever,  and  various  other  disorders,  which  we  enumerated  while  treat- 
ing of  pessaries,  and  which  we  shall  not  here  recapitulate. — (See  p. 
249  et  seq.) 

In  addition  to  pessaries  forgotten  in  the  vaginal  cavity,  examples 
of  other  bodies  are  cited,  whose  detention,  even  for  a short  time, 
have  produced  very  serious  disorders. 

The  celebrated  Dupuytren*  was  called  to  a woman  who,  with 
intentions  she  cared  not  to  confess,  had  introduced  into  her  vagina  a 
small  Delft  pomatum-pot;  as  the  introduction  of  the  little  vase, 
which  was  of  conoidal  form,  had  been  made  by  the  base,  and  as 
its  presence  in  the  vagina  had  occasioned  swelling  and  tumefaction 
of  the  mucous  membrane  situated  below  it,  it  was  difficult  to  as- 
certain the  nature  of  the  foreign  body,  and  its  extraction  could 
only  be  accomplished  after  it  had  been  broken  by  means  of  strong 
pincers.  The  same  professor  also  states,  in  his  Legons  Orales , that 
he  once  had  occasion  to  extract  from  the  vagina  a great  number 
of  needles  which  had  fallen  within  that  cavity  from  a large  needle- 
case,  that  had  opened  after  its  introduction.  Although  the  records  of 
science  contain  other  observations  of  the  same  kind,  we  shall  rest 
content  with  quoting  one  which  is  very  recent,  and  which  is  reported 
in  a thesis  by  Dr  Grenier,  t 

In  the  year  1832,  an  unfortunate  idiot  female,  living  in  the  hospital 
de  la  Vieillesse , in  the  women’s  department,  passed  into  her  vagina 
a needle-case,  which  opened  and  allowed  the  needles  that  it  contained 
to  escape.  When  M.  Grenier  saw  the  patient,  she  was  suffering  the 
most  violent  pain,  her  face  expressed  the  greatest  anxiety  ; the  skin 
was  burning  hot,  and  she  experienced  constant  desire  to  urinate,  with 
impossibility  of  satisfying  it.  After  the  needles  had  been  removed, 
she  was  placed  in  a warm  bath  for  some  time,  an  anodyne  potion 
was  administered,  and  the  symptoms  soon  disappeared. 

The  operative  methods  to  be  employed  for  the  extraction  of  foreign 
bodies  in  the  vagina,  should  vary  according  to  their  nature  and 
situation.  The  surgeon  should  always  begin  by  exploring  the  va- 
gina, after  having  placed  the  patient  on  a bed,  in  the  position  indi- 
cated for  the  application  of  the  speculum.  When  the  nature,  form 
and  situation  of  the  foreign  body  or  bodies  have  been  exactly  ascer- 
tained, the  operator  must  disengage  and  take  them  away,  either  with 
his  fingers,  with  pincers,  a scoop,  a blunt  hook,  and  sometimes  even 
with  a terebra.  The  speculum,  with  movable  blades,  may,  in  some 
cases,  be  useful  to  dilate  the  external  orifice  of  the  vagina,  and  in 
this  way,  assist  the  escape  of  pricking  or  irregular  bodies,  by  pro- 
tecting the  tumefied  and  irritated  parts  through  which  they  must 
pass  in  order  to  escape.  If  the  foreign  body  cannot  be  extracted 
entire,  as  often  happens  in  the  case  of  pessaries  forgotten  in  the 
vagina,  it  becomes  necessary  to  break  or  divide  it  while  in  that 
cavity,  by  means  of  strong  pincers  or  long  cutting  forceps. 

* Lecons  Orales,  1827.  f Dissert,  sur  les  corps  Strangers,  Paris,  1834. 


268 


FOREIGN  BODIES  IN  THE  WOMB. 


After  these  operations,  which  are  often  very  difficult,  and  always 
painful,  it  is  proper  to  prescribe  demulcent  and  narcotic  injections, 
conjointly  with  some  sedative  potion  at  first,  and  then  with  a view 
to  prevent  and  combat  inflammatory  symptoms,  we  must  resort  to 
strict  diet,  to  emollient  enemata  and  fomentations,  and,  finally,  to  the 
application  of  leeches  to  the  hypogastric  region,  and  even  to  general 
bleeding,  if  the  violence  of  the  inflammation  should  require  it. 

It  is  very  rare  for  foreign  bodies  to  be  introduced  into  the  uterus 
through  its  vaginal  orifice  or  its  parietes,  except  during  pregnancy, 
because  in  the  state  of  vacuity,  it  is  so  small,  and  has  so  small  a 
cavity,  that  it  is  almost  impossible  for  this  kind  of  lesion  to  take  place. 
M.  Crouzit,  of  Rochechouart,  has  published  a very  interesting  case 
of  a female  who,  with  criminal  intentions,  had  introduced  a seton- 
needle  through  her  vagina  and  os  tineas,  which  escaped,  and  was 
lost  in  the  uterine  cavity,  whence  it  did  not  pass  out  until  after  the 
lapse  of  seventy-nine  days,  and  then  through  one  of  the  groins. 
The  same  practitioner  adds  that  the  presence  of  the  needle  in  the 
womb,  and  the  perforations  which  took  place  during  its  escape  ex- 
ternally, gave  rise  to  serious  disorders  and  to  a metro-peritonitis, 
which  brought  the  patient  to  the  very  gates  of  death. 

The  accidental  introduction  of  foreign  bodies  into  the  canal  of  the 
female  urethra  is  extremely  rare.  Nevertheless,  the  annals  of  the 
science  possess  some  examples  of  the  kind,  since  hair-pins  and 
other  analogous  bodies  introduced  to  satisfy  a childish  curiosity,  or 
during  an  attack  of  erotomania,  have  been  removed,  either  through 
the  urinary  meatus,  or  by  means  of  an  incision  made  into  the  blad- 
der, for,  when  caught  in  this  organ,  they  could  not  be  removed 
through  the  canal  by  which  they  had  been  introduced. 

To  extract  foreign  bodies  and  even  calculi  engaged  in  the  meatus 
urinarius,  the  woman  should  be  placed  as  we  have  described  above; 
then  having  prepared  the  canal  of  the  urethra  with  some  oily  injec- 
tion, we  may  employ  the  ring  forceps,  or,  still  better,  what  is  called 
Hunter’s  forceps.  When  the  operation  is  terminated,  we  should 
prescribe  protracted  warm  bathing,  narcotics  and  antispasmodics 
internally,  and,  finally,  local  capillary  blood-letting. 


FOURTH  SECTION. 

CHAPTER  VIII. 

VITAL  AND  ORGANIC  LESIONS. 

We  include  amongst  the  vital  and  organic  lesions  all  superficial 
and  deep-seated  inflammations,  degenerations,  excrescences,  transfor- 
mations, and,  in  fine,  all  morbid  productions  of  the  vulva,  vagina, 
uterus,  Fallopian  tubes,  ovaries  and  mammae. 


PRURIGO  OF  THE  VULVA. 


269 


SUPERFICIAL  INFLAMMATION  OF  THE  VULVA. 

The  external  parts  of  generation  in  the  female  are  liable  to  dif- 
ferent superficial  inflammations,  which  vary  in  degree,  according  to 
the  causes  which  have  produced  and  which  maintain  them.  In 
female  infants  at  the  breast,  the  contact  of  the  urine  and  foecal  mat- 
ters, often  gives  rise  to  erythema  and  painful  excoriations  of  the  mu- 
cous and  cutaneous  surfaces  of  the  Jabia  majora,  which  may,  in 
some  cases,  if  neglected,  become  the  origin  of  severe,  gangrenous, 
and  fatal  erysipelas.  Such  unfortunate  results  may  easily  be  avoided, 
by  due  attention  to  cleanliness,  and  we  may  cure  the  superficial  in- 
flammations of  the  vulva  by  the  use  of  baths  and  emollient  fomenta- 
tions, and  by  the  application  of  pledgets  of  linen  covered  with  cerate, 
or  imbibed  with  oil  beaten  in  pure  water  or  lime  water.  The 
powder  of  lycopodium  and  of  starch,  or  of  worm-eaten  wood  is 
likewise  useful  when  the  parts  are  too  much  relaxed,  or  are  the  seat 
of  a sero-mucous  discharge. 

The  neglect  of  cleanliness  may  also  produce  troublesome  conse- 
quences in  girls  of  more  advanced  age;  for  their  external  genital 
parts  are  often  the  seat  of  a very  acute  inflammation,  caused  by 
sebaceous  white  and  concrete  matters,  which  have  been  allowed  to 
collect  and  become  rancid  around  the  clitoris  nymphse  and  in  the 
folds  of  the  vulva,  where  they  are  secreted.  From  these  kinds  of 
irritation,  smarting  pains,  and  often  intolerable  itching,  arise,  which 
excite  to  repeated  handling,  and  even  to  an  irresistible  propensity 
to  masturbation.  This  unfortunate  habit  also  arises  from  the  pru- 
ritus aroused  by  vermicular  ascarides  which  have  passed  from  the 
rectum  into  the  folds  of  the  vulvo-vaginal  mucous  membrane.  To 
remove  this  cause  of  irritation,  it  is  sufficient  to  keep  the  parts  clean, 
and  to  make  use  of  vermifuge  lotions  and  injections. 

The  superficial  inflammations  of  the  vulva,  caused  by  erotic  ex- 
cesses of  coitus  or  by  solitary  vice,  are  usually  soon  cured  by  repose 
of  the  parts,  by  demulcent  and  acidulated  drinks,  by  the  application 
of  leeches  to  the  external  surface  of  the  labia  majora,  and  especially 
by  the  use  of  emollient  and  gelatinous  baths.  Those  which  are  due  to 
an  exanthema,  as  variola,  or  measles,  etc.,  disappear  with  the  general 
disease,  to  which,  therefore,  we  should  chiefly  direct  our  attention. 

Finally,  erysipelas  of  the  vulva,  which,  like  erysipelas  of  other 
portions  of  the  body,  may  be  accidental,  spontaneous,  fixed,  irregular 
or  wandering,  requires  nothing  in  particular,  except  to  prevent  adhe- 
sion of  the  inflamed  parts,  by  the  frequent  use  of  emollient  injections 
into  the  vagina,  and  the  introduction  into  the  canal  of  a large  plug  of 
charpie  or  a tampon  of  soft  linen,  soaked  in  some  mucilaginous  de- 
coction. 


OF  PRURIGO  OF  THE  VULVA. 

This  affection,  characterized  by  violent,  intolerable  itching  and  ex 
cessive  smarting  of  the  vulva,  may  be  seated  in  the  labia  majora 


270 


PRURIGO  OF  THE  VULVA. 


alone,  or  may  extend  to  the  mucous  membrane  of  the  orifice  of  the 
vagina,  and  even  to  the  mons  veneris.  It  has  frequently  been  mis- 
taken for  a true  herpetic  eruption,  some  of  whose  characters  it  pre- 
sents, jmst  as  in  some  cases  the  itching,  which  has  been  attributed  to 
it,  was  in  fact  due  to  the  presence  of  parasitic  animals  (pediculi-pubis). 

. The  circumstances  under  whose  influence  prurigo  of  the  vulva 
most  frequently  occurs,  are  the  change  of  life,  pregnancy,  and  the 
approach  and  derangements  of  menstruation,  especially  in  women 
subject  to  acrid  discharges,  and  who  are  inattentive  to  the  calls  of 
cleanliness. 

The  chief  symptom  of  this  malady  is  a pruritus,  which  augments 
in  proportion  as  the  patient  yields  to  it.  The  itching  is  most  intense 
when  the  patient  is  in  bed,  and  after  eating  and  exercise,  especially 
in  situations  where  the  temperature  is  high.  The  disorder  usually 
has  intermissions  of  some  hours,  and  even  days.  Upon  examining 
the  parts,  we  discover  little  pimples,  scarcely  distinguishable  and 
slightly  raised  into  points.  When  inflamed  but  slightly,  they  con- 
tain no  matter;  but  when  torn  by  the  nails,  they  secrete  a little  drop 
of  sanguineous  serosity,  which  by  its  desiccation  forms  a brown  crust 
of  the  size  of  a millet  seed. 

When  the  disease  is  slight,  which  is  commonly  the  case,  it  readily 
yields  to  the  employment  of  some  of  the  topical  remedies  that  we 
shall  mention;  in  the  contrary  case,  especially  when  the  affection  is 
of  long  standing,  the  epidermis  becomes  hard  and  exfoliates,  the 
patient,  tormented  without  cessation,  soon  emaciates,  and  often  falls 
into  a state  of  melancholy  and  despair. 

If  the  prurigo  have  commenced  during  pregnancy,  or  during  the 
flow  of  the  menstruae,  it  is  necessary  merely  to  moderate  the  itch- 
ing by  means  of  emollient  and  narcotic  lotions;  we  have  em- 
ployed in  these  cases,  and  always  with  advantage,  lotions  of  warm 
water,  with  addition  of  a tablespoonful  of  Cologne  water  to  each 
teacupful  of  the  former  fluid.  It  is  proper  to  remark,  however,  that 
the  itching  does  not  cease  entirely  in  the  first  case  until  after  the  wo- 
men are  confined,  and  in  the  second  until  after  the  close  of  the  men- 
strual evacuation.  When  the  disease  coincides  with  amenorrhoea  or 
with  inflammation  of  the  womb,  it  commonly  disappears  after  the 
re-establishment  of  the  suppressed  flux  and  the  cessation  of  the  phleg- 
masia, which  alone  ought  to  engage  the  attention  of  the  physician. 

In  all  other  cases,  we  should  add  to  the  means  just  enumerated 
the  use  of  simple  and  sulphurous  baths;  and,  should  the  inflamma- 
tion be  acute,  the  application  of  leeches.  In  his  work  upon  diseases 
of  the  skin,  Dr.  Wilson  recommends  lotions  of  twelve  grains  of  cor- 
rosive sublimate  in  eight  ounces  of  lime  water,  to  be  frequently  re- 
newed; M.  Trousseau  has,  also,  prescribed  advantageously  lotions 
of  a solution  of  three  drachms  of  subcarbonate  of  potash  to  four 
ounces  of  distilled  water,  of  which  a teaspoonful  must  be  put  into  a 
basin  containing  about  two  pounds  of  warm  water;  the  proportion 
of  the  solution  was  gradually  augmented,  each  day,  until  slight 
sweating  was  produced.  The  same  practitioner  also  prescribes 
lotions  with  a mixture  of  two  drachms  of  corrosive  sublimate,  dis- 


PRURIGO  OF  THE  VULVA. 


271 


solved  in  a sufficient  quantity  of  alcohol,  and  ten  ounces  of  distilled 
water.  This  solution  he,  at  first,  employed  in  the  proportion  of  a 
teaspoonful  to  a pound  of  warm  water,  and  successively  of  three  or 
four  tablespoonfuls,  to  he  applied  by  washing  two  or  three  times  a 
day.  While  these  lotions,  which  were  continued  some  days  after 
the  cessation  of  all  the  symptoms,  were  employed,  M.  Trousseau 
prescribed  the  use  of  diluent  drinks  and  of  some  laxative,  and  for- 
bade wine,  cordials  and  acrid  stimulant  and  spiced  food. 

In  cases  of  idiopathic  prurigo,  we  have  employed,  with  advantage, 
cold  lotions  made  with  a very  weak  solution  of  sulphate  of  zinc,  iron 
or  alum;  Goulard’s  lotion,  oxycrate,  laudanum  mixed  with  water, 
have  also  sometimes  succeeded  in  our  hands;  Dr.  Ruan,*  (of  Phila- 
delphia,) in  cases  of  very  obstinate  prurigo,  has  obtained  cures  by 
the  internal  use  of  balsam  of  copaiba,  of  carbonate  of  soda,  and  by 
the  external  application  oft  bread  and  milk  poultices,  with  additions 
of  laudanum ; finally,  by  the  use  of  lotions  made  with  a solution  of 
powdered  sub-borate  of  soda,  or  of  carbonate  of  zinc.  If  active 
inflammation  should  supervene  after  the  employment  of  these  reme- 
dies, as  we  have  known  to  happen,  it  should  be  combated  by  general 
and  local  emollient  and  narcotic  baths,  or  by  baths  of  gelatine  or  of 
bran.  Finally,  in  very  obstinate  cases,  slight  cauterizations  with  the 
nitrate  of  silver,  or  even  with  the  actual  cautery,  have  been  employed 
with  success,  and  triumphed  over  a disease  which  had  resisted  all 
other  means.  We  should  never,  however,  forget  that  the  too  sudden 
suppression  of  the  prurigo  may  be  followed  by  serious  disorders, 
which  it  is  possible  to  prevent  by  means  of  a large  blister  applied  to 
one  of  the  arms,  or,  still  better,  to  one  of  the  thighs. 

[I  have  not  any  thing  special  to  add  to  M.  Colombat’s  article,  except  an 
account  of  the  successful  use  of  Dr.  Ruan’s  remedy  with  some  modification. 
The  late  Prof.  Dewees,  of  this  city,  so  long  and  so  well  known  as  a prac- 
titioner at  the  head  of  his  profession  in  this  country,  used  to  speak  of  cases 
of  this  kind,  in  which  the  inner  surface  of  the  genital  parts  was  covered 
with  aphthae,  very  like  the  aphthae  faucium  ; and  it  was  in  these  cases  that 
he  strongly  recommended  the  borate  of  soda,  agreeably  to  the  experience  of 
my  venerable  fellow-citizen,  Dr.  John  Ruan,  also  a person  of  great  clinical 
experience. 

I confess  that  I have  not  perceived,  upon  examination,  nor  have  I been 
informed  by  the  patient,  of  the  aphthous  condition  of  the  mucous  surface, 
but  I have  found  it  excessively  red  and  dry,  and  the  subject  of  the  most 
insupportable  pruritus, — which  has  continued  to  torture  the  sufferer  for 
months,  and  until  the  gestation  has  concluded,  notwithstanding  all  the 
efforts  that  could  be  directed  against  it.  But  I am  free  to  say,  having  been 
a great  many  times  consulted  for  the  relief  of  pruritus  vulvae,  and  most  fre- 
quently in  pregnant  women,  I have  rarely  had  occasion  to  order  any  thing 
more  than  the  following  formula,  viz: 

* Revue  Medic.,  tom.  i.  p.  305,  1829.  From  the  North  Amer.  Med.  and  Surg. 
Journ.,  1828. 


212 


OF  PHLEGMON  OF  THE  LABIA  MAJORA. 


R. — Sodae  borat.  3ss. 

Morph iae  sulphat.  gr.  vj. 

Aq.  rosae  destillat.  3 viij. 

M. — F.  to  sec.  art.  misturae. 

I direct  the  person  to  apply  it  thrice  a day  to  the  affected  parts,  by  means 
of  a bit  of  sponge  or  a piece  of  linen,  taking  the  precaution  first  to  wash 
the  surfaces  with  tepid  water  and  soap,  and  to  dry  them  before  applying  the 
lotion.  I can  confidently  recommend  the  prescription  as  suitable  in  most  of 
the  cases  of  this  most  annoying  malady. — M.] 

OF  PHLEGMON  AND  DEEP-SEATED  INFLAMMATION  OF  THE  LABIA 

MAJORA. 

Phlegmon  of  the  labia  majora  is  far  from  being  rare  ; for  independ- 
ently of  that  developed  after  contusions  occurring  during  labour  or 
the  sexual  congress,  and  shocks  of  other  kinds,  there  are  some  which 
commence  without  our  being  able  to  discover  the  cause.  Females 
recently  married  are  much  more  subject  to  them  than  those  more 
advanced  in  years ; in  some,  this  kind  of  phlegmon  is  reproduced  at 
each  appearance  of  the  menstrual  discharge ; they  present  nothing 
peculiar,  except  that  they  almost  always  terminate  by  suppuration  ; 
their  treatment  consists  in  the  employment  of  emollient  and  matu- 
rative  poultices,  low  diet,  local  bleedings,  &c. ; when  suppuration 
takes  place,  the  abscess  must  be  opened  by  a longitudinal  incision 
on  the  internal  surface  of-  the  labium  externum.  In  the  periodical 
phlegmon,  however,  a simple  incision  is  not  sufficient,  because,  in 
cases  of  this  kind,  the  walls  of  the  abscess  are  smooth  like  those  of  a 
cyst;  they  unite  with  difficulty,  and  on  this  account  should  be  irri- 
tated by  means  of  injections  capable  of  producing  granulations  upon 
their  surface.  These  injections,  which  it  is  necessary  to  use  two  or 
three  times  a day,  may  be  made  simply  with  equal  parts  of  wine 
and  water,  or  with  a mixture  of  an  ounce  of  rose-water  and  a 
drachm  of  aqua  ammonias. 

Abscesses  of  the  vulva,  which,  from  feelings  of  shame,  have  been 
left  without  treatment,  terminate  in  tortuous  sinuses  communicating 
with  the  rectum,  and  thus  occasion  fistula  of  the  labium  externum 
by  giving  passage  to  stercoraceous  matter;  these  should  be  largely 
opened  with  a narrow  bistoury. 

Dr.  Vidal  de  Cassis*  has  lately  described  certain  small  abscesses, 
which  occur  around  the  vulva  during  blennorrhagia,  and  which  are 
very  common  amongst  prostitutes.  In  the  opinion  of  this  practi- 
tioner, these  abscesses,  though  but  little  known,  merit  serious  atten- 
tion; for  they  are  almost  always  followed  by  fistula  and  sometimes 
even  by  very  serious  nervous  symptoms.  As  this  is  not  the  proper 
place  to  detail  their  history,  we  shall  rest  content  with  saying  that 
they  appear  during  the  progress  and  even  towards  the  termination  of 
the  blennorrhagia,  that  they  are  generally  seated  in  the  substance  of 
the  labia,  of  the  vulva  and  especially  at  the  point  where  the  nymphae 

* Traite  de  Pathologie  Chirurgicale,  t.  i.  p.  246,  1838. 


GANGRENOUS  INFLAMMATION  OF  THE  LABIA  MAJORA.  273 


terminate  in  the  labia  majora.  The  purulent  collection  being  com- 
monly inconsiderable,  these  abscesses,  though  painful,  remain,  for 
some  time,  undetected,  and  their  existence  is  often  declared  only 
because  the  pus,  nearer  to  the  mucous  membrane  than  to  the  skin, 
comes  at  last  to  bathe  the  edges  of  the  vulva,  after  having  opened  a 
passage  for  itself. 

[It  appears  to  me  that  the  author  ought  to  have  guarded  the  young  and 
inexperienced  practitioner  against  the  danger  of  making  a mistake  in  the 
diagnosis  of  these  affections.  At  least  should  he  have  referred  him  back  to 
page  206,  for  the  diagnosis  of  vulvar  enterocele.  Nothing  could  be  more 
dreadful  than  to  plunge  a lancet  into  the  intestine,  confined  within  the 
labium  of  a patient,  under  the  mistaken  design  of  discharging  a supposed 
abscess. — M.] 

GANGRENOUS  INFLAMMATION  OF  THE  LABIA  MAJORA. 

The  external  genital  organs  of  the  female,  like  the  vagina,  some- 
times become  the  seat  of  gangrenous  sloughs,  produced  by  the 
violent  pressure  of  the  foetal  head  during  labour.  In  other  cases 
gangrenous  affections  of  the  external  genital  parts  prevail  epidemi- 
cally in  hospitals  for  lying-in-women,  and  are  then  one  of  the  symp- 
toms of  a typhoid  fever,  or  of  a metritis,  which  is  almost  always 
fatal. 

The  treatment  of  symptomatic  gangrenous  affections  consists  in 
uniting  the  utmost  cleanliness  together  with  emollient  ablutions  to 
the  treatment  of  the  principal  disease;  then  in  the  use  of  tonic 
lotions  made  with  honeyed  wine  of  cinchona,  or  lotions  with  Labar- 
raque’s  disinfecting  solution. 

There  is  a kind  of  primitive  gangrene,  happily  very  rare,  which 
has  been  designated  by  the  term,  carbuncle  of  the  genital  organs . 
The  disease,  which  is  extremely  dangerous,  commences  sometimes 
with  phagedsenic  ulceration,  or  by  oedematous,  but  more  frequently 
by  phlegmonous  engorgement  When  it  begins  in  the  latter  form, 
the  pain  at  first  is  very  acute  and  the  heat  intense ; the  swelling 
shows  itself  particularly  about  the  mans  veneris;  the  integuments 
are  of  a dusky-red  colour,  and  present  a smooth  and  shining  aspect. 
A progressive  diminution  of  sensibility,  and  the  appearance  of  a 
violet  spot,  depressed  in  its  centre,  and  becoming  more  and  more 
deeply-coloured,  announce  the  approaching  attack  of  gangrene, 
which  speedily  iuvades  the  neighbouring  parts  and  spreads  to  an 
extent  that  varies  with  the  duration  of  the  disease : the  prognosis 
of  this  affection  is  always  very  grave;  for  it  almost  always  termi- 
nates fatally.  The  treatment  consists  of  local  depletion,  topical  ap- 
plications of  refrigerant  detergents,  and  emollient  applications  ac- 
cording to  circumstances ; if  the  disease  begin  with  oedematous 
engorgement,  blisters  and  the  actual  cautery  might  stay  its  progress. 
It  would  be  proper,  also,  to  resort  to  vinous,  alcoholic,  camphorated 
and  chlorinated  lotions,  or  those  made  with  decoction  of  cinchona; 
internally,  the  mineral  acids,  anti-scorbutics  and  the  preparations  of 
18 


274 


ACUTE  INFLAMMATION  OF  THE  VAGINA. 


cinchona  should  likewise  be  employed,  especially  if  the  march  of 
the  disease  should  seem  sensibly  arrested  by  the  remedies  first  put  in 
practice. 

ACUTE  INFLAMMATION  OF  THE  VAGINA. 

Although  acute  inflammation  of  the  vagina  generally  coincides 
with  that  of  the  womb,  which  is  soon  to  occupy  us,  it  may,  never- 
theless, exist  separately,  or  at  least  extend  only  to  the  mucous  mem- 
brane of  the  vulva,  which  at  the  same  time  becomes  the  seat  of  a 
more  or  less  abundant  exudation. 

Acute  vaginitis  may  be  produced  by  erotic  excesses,  resulting  from 
repeated  coitus,  or  from  solitary  vice;  by  irritating  injections;  by  the 
detention  of  hard  and  voluminous  foreign  bodies  in  the  vagina ; by 
violation,  especially  if  committed  upon  a person  of  tender  age;  by 
obstetrical  operations;  by  venereal  infection;  and,  finally,  by  any 
agent  capable  of  producing  an  irritating  action  in  the  vulvo-vaginal 
mucous  membrane. 

Whatever  be  the  cause  of  this  affeetion,  it  begins  with  slight  pru- 
ritus and  sensation  of  weight  in  the  genital  parts ; the  patient  feels 
a kind  of  constriction  at  the  vagina,  or  dragging  in  the  groins,  with 
vague  pains  in  the  hypogastric  region,  in  the  hips  and  loins;  the  pru- 
ritus, at  first  slight,  soon  changes  into  a painful  and  burning  sensation, 
especially  during  the  discharge  of  urine.  Tumefaction  occurs  along 
the  whole  length  of  the  vagina,  which  is  sometimes  so  considerable 
as  to  make  it  difficult  to  introduce  the  finger.  On  the  third  or  fourth 
day,  a limpid  and  not  very  abundant  mucous  discharge  is  established. 
The  desire  to  urinate  becomes  more  frequent,  and  the  pain  which 
accompanies  it  more  acute : little  by  little  the  discharge  increases 
and  varies  in  colour,  white,  yellow  or  greenish,  and  sometimes  the 
local  inflammation  becomes  so  intense  that  even  fever  arises,  and 
the  vaginal  secretions  excoriate  the  greater  and  lesser  labia.  When 
the  inflammation  has  extended  as  far  as  the  os  tincae,  the  patient 
feels  a sensation  as  of  a large  tumour  causing  weight  at  the  bottom 
of  the  vagina,  especially  when  she  tries  to  walk.  In  performing 
the  Touch,  which  is  generally  very  painful,  we  find  the  neck  of  the 
uterus  swollen,  sensitive  and  burning;  if  we  resort  to  exploration  by 
means  of  the  speculum,  the  circumference  of  the  mouth  of  the  womb 
is  seen  to  be  red,  tumefied  and  often  excoriated. 

Ordinarily  the  symptoms  begin  to  decrease  towards  the  tenth  or 
twelfth  day,  the  discharge  gradually  loses  its  colour,  and,  finally,  the 
inflammation  terminates  by  resolution  and  soon  disappears,  unless 
it  pass  into  the  chronic  form.  It  happens,  nevertheless,  that  in  some 
cases  acute  vaginitis  terminates  in  suppuration,  giving  rise  to  indo- 
lent abscesses  which  might  be  mistaken  for  vaginal  enterocele,  and 
this  the  more  probably  because  the  tumours  which  result  from  them 
are  soft  and  insensible,  and  the  pus  they  contain  disappears  under 
the  pressure  of  the  fingers,  as  the  loop  of  intestine  does  when  we 
effect  its  reduction.  When  the  vaginal  inflammation  is  the  result  of 
a mechanical  lesion,  it  frequently  terminates  in  gangrene,  which, 


ACUTE  INFLAMMATION  OF  THE  VAGINA. 


275 


after  the  fall  of  the  sloughs,  occasions  a loss  of  substance,  producing 
recto  and  vesico-vaginal  fistula. 

The  treatment  of  acute  vaginitis,  not  dependent  upon  syphilis, 
consists  in  the  use  of  baths,  of  emollient  and  narcotic  lotions  and 
injections,  and  of  general  or  local  depletion,  according  to  the  violence 
of  the  symptoms ; to  these  should  be  added  diluent  drinks,  sedative 
and  demulcent  enemata,  rest,  strict  diet,  or  at  least  mild  and  light  food, 
and  the  treatment  is  concluded  with  astringent  lotions  and  injections. 
Should  the  disease  terminate  by  suppuration,  it  is  necessary  to  open 
the  abscess  as  soon  as  it  is  detected  ; and  in  case  gangrenous  sloughs 
form,  we  must  resort  to  tonic  and  chlorinated  lotions. 

Although  we  do  not  intend  in  this  work  to  treat  of  diseases  belong- 
ing properly  to  general  pathology,  such  for  example  as  the  venereal 
disease,  we  shall,  nevertheless,  make  some  remarks  upon  contagious 
vaginitis  or  blennorrhagia  of  the  female. 

The  contagious  character  is  not  inherent  in  that  form  of  vaginitis 
only  which  results  from  an  impure  coitus;  for,  it  has  long  since 
been  proved,  that  when  once  established  under  the  influence  of  any 
cause  whatsoever,  it  may,  during  the  venereal  act,  communicate  an 
urethral  blennorrhagia  to  a male. 

This  contagious  property  of  vaginitis  is  not  a constant  one ; it  may 
be  developed  under  some  circumstances,  and  cease  to  be  manifested 
under  others.  It  has  been  known,  after  having  been  for  a long  time 
innocent,  to  become  contagious  after  the  woman  has  committed 
excesses  in  eating,  after  frequently-repeated  sexual  intercourse,  or 
even  after  violent  exercise.  What  is  most  worthy  of  remark  is,  that 
the  affection  contracted  from  a female  labouring  under  vaginitis  is 
not  invariably  a blennorrhagia,  but  consists  often  of  ulcerations  or 
of  vegetations,  etc.  It  is  proper  to  say,  however,  that  the  power  of 
giving  rise  to  these  different  symptoms  is  not  common  to  all  forms 
of  vaginitis,  but  that  it  seems  to  belong  especially  to  that  which  is  of 
syphilitic  origin. 

It  is  much  to  be  desired  that  some  external  signs  could  be  discovered 
by  which  we  might,  from  the  very  first,  distinguish  whether  a case 
of  vaginitis  is  or  is  not  contagious ; unfortunately,  the  symptoms  just 
described  have  nothing  decisive  in  them,  and  are  often,  indeed,  quite 
uncertain.*  Although,  in  general,  we  may  affirm  a vaginal  discharge 
to  be  contagious  when  the  redness  is  acute,  the  pain  intense,  and  the 
swelling  considerable  ; when  the  urethra,  conjointly  with  the  vagina 
is  very  much  inflamed;  in  a word,  when  the  inflammation  is  violent'; 
we  cannot  assert  that  blennorrhagia  may  not  be  communicated 
by  contagion  even  when  it  is  slight  in  appearance,  and  fails  to  pre- 
sent the  symptoms  we  have  enumerated. 

We  shall  conclude  with  the  statement,  that  when  fully  convinced 
that  vaginitis  is  the  result  of  syphilitic  infection,  we  should  com- 
bine with  the  antiphlogistic  treatment  the  use  of  mercurials  and 

* The  chemical  and  microscopic  researches  of  Dr.  Donne  have,  in  great  measure, 
enlightened  this  difficult  point  of  diagnosis.  We  do  not  mention  them  here,  because 
we  shall  describe  them  in  treating  of  the  characters  which  distinguish  syphilitic  vagi- 
nitis and  leucorrhcea  properly  so  called. 


276 


ACUTE  INFLAMMATION  OF  THE  WOMB. 


various  other  means  we  shall  mention  in  speaking  of  chronic  catarrh 
of  the  vagina  and  uterus.  Lastly,  if  the  disease  be  connected  with 
a scrofulous,  herpetic,  rheumatic  or  verminous  disorder,  etc.,  the 
treatment  ought  in  the  same  way  to  be  directed  to  the  principal 
disease,  without  however  omitting  the  local  remedies,  especially 
resolvent,  astringent,  tonic,  opiate,  mercurial  and  balsamic  injections, 
etc.  We  might  also  resort  to  cauterization  with  the  solid  nitrate  of 
silver,  which  our  fellow-practitioner  and  friend,  M.  Ricord,  has  em- 
ployed with  the  greatest  success  in  the  treatment  of  acute  and  chronic 
vaginitis,  and  which  we  have  likewise  employed  for  six  years  past, 
in  order  to  modify  and  cure  several  different  affections  of  the  vocal 
organs.  When  speaking  of  the  treatment  of  leucorrhoea  or  vagino- 
uterine  catarrh,  we  shall  describe  the  method  followed  by  M.  Ricord, 
who  calls  the  nitrate  of  silver  the  antiphlogistic  caustic. 

[In  the  treatment  of  vaginitis,  it  would  be  proper  to  keep  always  in  view 
the  liability  of  the  canal  to  become  greatly  injured  by  stricture  of  greater  or 
less  breadth,  and  even  by  the  occurrence  of  the  adhesive  inflammation,  end- 
ing in  complete  cohesion  of  large  portions  of  the  opposing  surfaces  of  the 
tube.  I beg  leave  to  refer  the  reader  to  page  101,  for  the  history  I have 
therein  related  of  such  a case,  with  the  mode  adopted  in  effecting  the 
cure.  The  misfortune  is,  that  the  modesty  of  the  patient  causes  her  almost 
invariably  to  conceal  from  the  medical  attendant,  any  secret  distress,  or  any 
disorder  that  might  expose  her  sensibility  to  some  shock  by  its  disclosure, 
and  hence  he  is  apt  not  to  discover  the  existence  of  disease  until  it  has  had 
time  to  produce  its  permanent  evil  effects. 

Knowing  this  disposition  of  the  female,  he  should  feel  bound  to  make 
such  occasional  inquiries  as  might  keep  him  fully  informed  of  any  threat- 
ened danger  to  the  object  of  his  care.  Complaints  being  made  to  him,  and 
neglected,  or  put  off  by  some  slight  direction  or  prescription,  become  serious 
charges  against  his  conscience,  should  they  be  followed  by  evil  consequences 
that  might,  by  proper  attention,  have  been  obviated. — M.] 

INFLAMMATION  OF  THE  PARENCHYMA  AND  LINING  MEMBRANE  OF 

THE  UTERUS. 

Notwithstanding  the  great  improvements  in  pathological  anatomy, 
yve  still  remain  imperfectly  acquainted  with  the  alteration  of  the 
parenchyma  produced  by  acute  inflammation  of  the  womb  : it  is 
easy  to  understand  why  there  still  remains  some  deficiency  in  the 
history  of  this  disease,  when  we  reflect  that  opportunities  for  observ- 
ing it,  and  especially  for  making  the  autopsy  of  persons  who  perish 
from  it,  seldom  occur. 

The  authors  who,  from  Hippocrates  down  to  the  middle  of  the 
last  century,  have  treated  of  acute  metritis,  do  not  always  agree  upon 
its  true  seat,  and  have  generally  published  only  imperfect  cases. 
Some  have  confounded  the  disease  with  uterine  catarrh,  others  with 
puerperal  peritonitis,  and  it  is  only  since  the  labours  of  Cigna,  per- 


ACUTE  INFLAMMATION  OF  THE  WOMB. 


277 


petual  secretary  of  the  Academy  of  Sciences  of  Turin*  have  been 
made  known,  that  physicians  universally  understand  by  acute  metri- 
tis, inflammation  of  the  proper  tissue  of  the  uterus. 

Where  the  inflammation  is  superficial,  that  is  to  say,  where  it  is 
seated  chiefly  in  the  lining  membrane  of  the  organ,  it  constitutes  the 
catarrhal  metritis  which  received,  in  1822,  from  Doctor  Blatin,t 
the  name  of  uterine  catarrh,  which  is  now  generally  adopted.  But,  as 
these  two  kinds  of  inflammation  rarely  exist  separately,  and  as  their 
causes,  symptoms  and  treatment  offer  but  slight  and  unimportant  dif- 
ferences, we  shall  describe  them  under  the  common  denomination  of 
metritis,  while  recording  the  symptoms  that  serve  to  distinguish 
whether  the  inflammation  predominates  in  the  mucous  membrane  of 
the  womb,  in  the  parenchyma  of  the  organ,  or  whether  it  occupies 
either  of  these  parts  exclusively. 

This  affection  is  very  rare  before  the  age  of  puberty,  because,  up 
to  that  epoch,  the  womb  remains  in  a kind  of  atrophy  and  inactivity, 
which  render  it  passive  as  it  were,  in  the  midst  of  the  living  economy. 
Nevertheless,  acute  metritis  is  sometimes  observed  in  little  girls  of 
early  age.  Doctor  Dance, X amongst  others,  has  published  a case 
which  seems  to  have  been  the  sequela  of  a chronic  peritonitis. 

Acute  inflammation  of  the  uterus  is  also  rare  in  women  who  have 
passed  the  critical  age  ; it  particularly  attacks  marriageable  girls 
during  menstruation,  persons  who  indulge  to  excess  in  the  pleasures 
of  venery,  in  masturbation,  and  still  more  those  in  the  lying-in  state, 
or  who  have  been  recently  delivered.  Sometimes  it  has  been  observed 
to  come  on  during  pregnancy,  and  cause  abortion  ; it  may  extend  to 
the  whole  uterus,  or  occupy  the  body  and  fundus  of  the  organ  alone. 

The  causes  that  may  give  rise  to  acute  metritis  are  very  nume- 
rous ; some  of  them  are  common  to  all  the  phlegmasise,  while  others 
having  a more  direct  action  upon  the  uterus  are  divided  into  predis- 
posing and  efficient  causes.  Amongst  the  former  are  youth,  an  erotic 
and  sanguine  temperament,  acute  sensibility  and  a first  labour. 

Amongst  the  efficient  causes  of  this  disease,  should  be  classed  pre- 
mature suppression  of  the  menstruse  ; too  frequently  repeated  coitus, 
and  absolute  and  relative  disproportion  of  the  organs;  solitary  enjoy- 
ment; celibacy;  widowhood  and  unsatisfied  desires  ; irritating  injec- 
tions ; suppression  of  hemorrhoidal  discharges;  leucorrhosa;  the  use 
of  violent  emmenagogues  employed  in  forcing  the  menses  or  in  pro- 
voking abortion  ; sudden  cooling  of  the  extremities ; cold  bathing  of 
the  vulva  and  vagina  ; cold  baths  and  iced  drinks,  especially  during 
menstruation  ; fatiguing  walks;  violent  exercise  on  horseback  or  in 
carriages,  without  springs  ; dancing  ; loss  of  sleep  ; wounds ; falls 
and  blows  on  the  hypogastric  region  ; the  application  of  a pessary; 
heating  and  stimulating  food ; highly-seasoned  meats ; spirituous 
drinks;  wine  ; coffee;  tonic, stimulating  and  aromatic  remedies  admi- 
nistered at  improper  times  ; moral  disturbances,  which  may  suspend 
the  flow  of  the  menstruee  and  of  the  lochia,  etc. 

* Uteri  inflammatio,  etc.,  dissert.,  Turin,  1756. 

f Du  catarrhe  uterin  ou  des  flueurs  blanches.  Paris,  an.  x. 

$ Archives  gener.  de  Medecine,  Octobre,  1829. 


278  ACUTE  INFLAMMATION  OF  THE  WOMB. 

The  causes  that  act  particularly  during  pregnancy,  are  premature 
labour,  immoderate  coitus,  and  the  introduction  of  a foreign  body 
into  the  womb  with  the  intention  of  producing  abortion,  and  falls  or 
blows  on  the  thighs  or  abdominal  region. 

Metritis  may  also  be  caused  during  labour  by  its  long  duration,  by 
manipulations  with  the  hands,  and  especially  with  the  forceps,  for  the 
purpose  of  effecting  the  version  of  the  child  or  the  detachment  of  the 
placenta;  by  lacerations  of  the  uterus;  by  too  often  repeated  examina- 
tions and  too  frequent  frictions  on  the  abdomen  to  excite  the  uterine 
contractions.  The  same  disease  may  be  determined  immediately  after 
delivery  by  the  retention  of  the  placenta,  or  some  of  its  connections, 
or  even  by  a coagulum;  by  the  injection  of  an  astringent  liquid,  or  of 
iced  water  into  the  vagina  and  uterus,  with  the  view  of  arresting 
haemorrhage ; by  the  employment  of  stimulating  drinks,  and  espe- 
cially of  roasts  cooked  with  wine,  cinnamon  and  nutmeg,  which  the 
nurses  have  the  habit  of  giving  to  women  recently  delivered,  in 
order  to  re-establish  their  strength ; finally,  metritis  may  be  occa- 
sioned by  sudden  suppression  of  the  lochia  or  milk,  produced  by 
rapid  cooling  of  the  body  or  by  a vivid  emotion,  as  fright,  joy,  anger, 
bad  news,  etc.  The  venereal  virus,  and  especially  cohabitation  with 
a person  affected  with  gonorrhoea,  are  likewise  causes  which,  in  all 
possible  conditions  of  society,  may  sometimes  occasion  the  develop- 
ment of  acute  inflammation  of  the  uterus. 

The  symptoms  of  the  disease,  which  may  be  either  idiopathic, 
symptomatic  or  metastatic,  and  which  is  often  determined  by  conti- 
nuity of  inflamed  organs,  are  divided  into  local  and  general,  which 
vary  according  as  the  inflammation  occupies  the  internal  mem- 
brane, the  neck,  the  fundus,  the  whole  or  a part  of  the  body  of  the 
organ. 

It  is  probable  that  the  inflammation  is  seated  chiefly  in  the  mucous 
membrane  of  the  cervix,  when  the  secretion  of  mucus  is  found  to  be 
abundant,  and  the  pain  slight ; especially  if  pressure  does  not  increase 
it ; and  finally,  where  the  cause  under  whose  influence  it  has  arisen, 
has  acted  principally  upon  the  lining  membrane  of  the  gestative  organ. 
We  may  be  almost  certain,  on  the  contrary,  that  the  inflammation 
occupies  particularly  the  substance  of  the  uterus,  when  there  is  no 
discharge  ; when  the  pain  is  very  acute  and  pulsative,  the  swelling 
very  marked,  and,  in  fine,  where  the  pain  has  manifested  itself  after 
a blow,  a puncture,  or  a fall  upon  the  hypogastric  region. 

When  the  inflammation  occupies  only  the  fundus  of  the  organ,  the 
pain  is  seated  towards  the  hypogastric  region  and  extends,  to  the 
umbilicus  ; if  the  metritis  be  puerperal,  the  pain  is  increased  by  pres- 
sure, and  the  tumour  is  very  sensitive  especially  at  its  upper  part.  If 
the  anterior  paries  be  affected,  the  painful  point  is  at  the  pubic  region, 
and  the  emission  of  urine  is  difficult  and  sometimes  impossible ; if 
the  posterior  wall  be  diseased,  the  expulsion  of  the  faecal  matter  is 
extremely  painful,  and  the  distress  in  the  loins  and  back  intolerable; 
the  female  feels  a sensation  of  weight  which  obliges  her  continually 
to  make  expulsive  efforts,  like  those  of  labour  or  of  defecation. 

When  the  inflammation  chiefly  occupies  the  lateral  portions  of  the 


ACUTE  INFLAMMATION  OF  THE  WOMB. 


279 


gestative  organ,  the  ligaments  participate  in  the  inflammatory  state, 
the  groins  and  thighs  are  painful,  the  legs  and  feet  are  benumbed,  the 
woman  lies  upon  her  back  with  the  inferior  extremities  drawn  up, 
for  any  other  position  is  insupportable. 

In  cases  where  the  neck  of  the  uterus  alone  is  affected,  the  patient 
feels  an  acute  pain  at  the  bottom  of  the  vagina;  if  the  phlegmasia 
has  succeeded  to  a laborious  labour,  there  occurs  from  the  vulva  a dis- 
charge of  blood  and  of  sanguineous  mucus  which  is  prolonged  beyond 
the  usual  period,  and  in  performing  the  Touch,  we  find  the  os  tincse 
hard,  swollen  and  always  more  or  less  torn.  When  on  the  other  hand 
it  has  followed  the  first  sexual  connection,  the  neck  only  is  swollen, 
burning,  very  sensitive,  and  seems  almost  always  to  be  nearer  to  the 
vulva.  In  general,  all  these  partial  inflammations  terminate  happily. 

It  is  not  so  where  an  acute  inflammation  occupies  the  whole  of  the 
womb;  the  symptoms  which  then  arise  are  al  ways  extremely  serious, 
because,  in  the  greater  portion  of  the  cases,  the  evil  extends  not  only 
to  the  uterine  serous  membrane,  but  also  to  the  rest  of  the  peritoneum. 

Metritis  generally  declares  itself  immediately  or  shortly  after  deli- 
very ; it  begins  with  rigors  of  longer  or  shorter  duration,  great  lan- 
guor, general  anxiety,  and  a dull,  gravative  and  sometimes  very 
acute  pain,  which,  commencing  in  the  hypogastrium,  extends  rapidly 
over  the  whole  abdomen. 

This  pain  is  continuous  ; it  is  much  increased  even  by  slight  pres- 
sure upon  the  lower  part  of  the  abdomen,  as  well  as  by  the  move- 
ments of  the  diaphragm  which  take  place  during  coughing,  the  act 
of  spitting,  deep  inspiration,  and  singultus,  etc.  The  patient  com- 
plains of  a sense  of  weight  about  the  rectum ; she  cannot  visit  the 
close  stool;  the  emission  of  urine  is  difficult,  painful,  and  often  impos- 
sible ; the  hypogastrium  enlarges,  becomes  more  and  more  sensitive, 
and  the  hand  applied  upon  that  region  finds  the  body  of  the  uterus 
harder  and  more  distended  than  in  the  normal  condition.  By  the  Touch , 
we  ascertain  that  the  neck  of  the  uterus  is  soft,  swollen,  extremely 
painful  and  always  warmer  than  the  vagina,  which, as  well  as  the  labia 
externa,  is  often  tumefied  and  inflamed.  If  the  metritis  have  occurred 
immediately  after  parturition, the  breasts  decrease,  milk  is  not  secreted, 
the  lochial  discharge  is  arrested,  and  the  same  takes  place  in  regard 
to  the  menstruse,  when  the  disease  coincides  with  the  period  of  that 
evacuation.  Sometimes  there  is  a more  or  less  abundant  discharge 
of  sanious  and  reddish  fluid,  and  in  certain  cases  the  patients  discharge 
both  fluid  blood  and  clots.  These  various  discharges,  which  are,  at 
times,  intermittent,  are  preceded  by  acute  pain,  caused  by  the  efforts 
of  the  womb  to  expel  the  materials  collected  in  the  cavity. 

As  the  viscus  has  very  intimate  sympathies  with  all  the  other 
organs  of  the  economy,  it  reacts  when  acutely  inflamed  upon,  those 
organs,  and  to  a greater  or  less  extent  disturbs  their  functions.  In- 
deed, certain  general  symptoms,  which  vary  according  to  the  intens- 
ity of  the  inflammation,  are  added  to  the  local  symptoms  which  we 
have  above  described. 

In  most  cases,  acute  metritis  is  preceded  by  rigor,  accompanied 
with  uneasiness  and  anxiety,  to  which  succeed  general  heat  of  the 


280 


ACUTE  INFLAMMATION  OF  THE  WOMB. 


skin,  fugitive  pains,  and  a sense  of  weight  about  the  uterus.  It  often 
happens  that  the  disease  makes  its  appearance  suddenly,  and  then 
we  observe  the  local  symptoms  which  are  peculiar  to  it  immediately 
after  the  attack.  When  the  disease  becomes  completely  established, 
the  general  and  local  symptoms  accompanying  it  are  great  change 
in  the  expression  of  the  features,  constant  restlessness,  extreme  feeble- 
ness, frequency  of  the  pulse,  heat,  dryness  of  the  tongue,  and  intense 
cephalalgia ; the  face,  which  bears  the  impress  of  suffering,  is  pale  and 
pinched  ; the  eyes  are  sunken  and  surrounded  by  a bluish  ring ; the 
tongue  is  cracked  and  dry,  white  or  yellowi^i  in  the  middle,  and  red 
at  the  point  and  edges ; the  thirst  is  great,  and  the  anexoria  intense ; 
the  patient  constantly  complains  of  constriction  in  the  throat;  she 
has  incessant  nausea,  often  amounting  to  vomiting;  sometimes  a fetid 
diarrhoea  or  obstinate  constipation  comes  on ; the  discharge  of  urine 
is  difficult  and  painful ; it  is  red,  loaded  and  irritating ; the  respiration 
is  suspirious  and  laboured,  partial  viscid  sweat  covers  the  forehead  ; 
the  sight  becomes  dim ; the  breasts,  which  are  also  painful,  become 
flaccid  and  shriveled;  but  this  phenomenon,  which  is  not  constant,  is 
very  apt  to  be  wanting  when  a discharge  from  the  vagina  has  been 
established.  Generally  speaking,  the  patient,  who  is  in  a state  of 
continued  wakefulness  and  wandering,  can  lie  only  on  the  back,  with 
the  legs  flexed  on  the  thighs,  and  the  latter  on  the  pelvis.  In  tine, 
when  to  these  symptoms  are  added  tympanitis,  singultus,  delirium, 
smallness  of  the  pulse,  picking  at  the  bed-clothes,  subsultustendinum, 
coldness  of  the  extremities,  excessive  prostration,  and  especially  a dis- 
charge of  blackish,  extremely  fetid  matter  from  the  vagina,  death  is 
not  far  from  the  victim.  This  affection,  which  rarely  destroys  the 
patient  before  the  end  of  the  first  week,  but  which  is  sometimes  pro- 
longed for  a fortnight  or  a whole  month,  may,  in  certain  cases,  reach 
such  a degree  of  intensity,  that  the  disorder  it  then  determines  in  the 
genital  functions  leads  to  a fatal  result  as  early  as  the  third  and  even 
the  second  day.  We  should  observe,  however,  that  a termination 
so  rapid  and  fatal  does  not  usually  occur  except  where  the  disease 
has  come  on  after  parturition,  because,  in  this  case,  the  inflammation 
extends  to  the  peritoneum.  * Moreover,  the  pus  that  is  formed  on  the 
lining  membrane,  in  the  parenchyma,  and  especially  in  the  sinuses 
of  the  womb,  is  often  absorbed  by  the  veins  of  the  organ,  and  thus 
mingled  with  the  blood  of  the  general  circulation,  goes  to  expend 
its  deleterious  activity  on  the  whole  economy.  It  is  this  purulent 
absorption  particularly  that  so  often  renders  puerperal  peritonitis 
fatal. 

It  often  happens,  where  the  inflammation  has  extended  to  the  peri- 
toneal coat,  or  into  the  substance  of  the  ligaments  of  the  womb,  that 
suppuration  takes  place  and  abscesses  are  formed  that  open  either 
into  the  cavity  of  the  peritoneum,  into  the  rectum,  the  bladder,  or  the 
vagina.  Sometimes,  also,  the  pus  forms  a passage  to  the  exterior 
surface ; for  example,  through  the  umbilical  region, * at  the  groin, t 

* Smellie,  Midwifery,  vol.  iii.  p.  444.  Lamotte,  Traite  d’Accouch.,  observ.  420. 
Pinel  .Nosograph.  philos.,  t.  ii.  p.  286.  Van  Swieten,  comment,  on  the  aphor.  of 
Boerhaave,  t.  iv. 

f Lamotte,  Trail©  d’Accouch.  (loco  citat.) 


ACUTE  INFLAMMATION  OF  THE  WOMB. 


281 


in  the  loins,  or  on  the  thigh, * and,  in  effecting  its  escape,  follows  some- 
times a direct  route,  and  at  others  burrows  through  the  cellular  tissue, 
in  a tortuous  course.  It  is  proper  to  remark,  however,  that,  as  these 
cases  have  been  observed  only  in  women  who  survived,  some  doubt 
may  perhaps  exist  as  to  the  point  of  departure  and  the  course  of  the 
suppuration.  Moreover,  as  the  dense  and  compact  structure  of  the 
womb  yields  but  slightly  to  the  formation  of  pus,  it  is  probable  that 
the  greater  part  of  the  purulent  collections  which  appear  externally, 
after  metritis,  are  developed  in  the  peritoneal  tissue,  or  in  the  neigh- 
bouring inflamed  organs,  and  not  in  the  uterine  parenchyma. 

Generally  speaking,  the  formation  of  pus  is  to  be  apprehended, 
when  the  symptoms  of  metritis  last,  with  undiminished  violence, 
beyond  the  second  week ; and  we  may  be  assured  of  its  occurrence 
where  the  pain  augments  and  becomes  pungent  or  pulsating  at  the 
same  time  that  fever  comes  on  with  transient  rigors  and  horripila- 
tion. Henceforward,  too,  the  uterine  and  alvine  evacuations  are  sup- 
pressed; night  sweats,  which  afford  no  relief,  come  on  ; the  patient  is 
attacked  with  extreme  restlessness,  with  more  violent  headache ; and 
it  is  the  diminution  of  these  symptoms  which  indicates  that  suppu- 
ration is  completed. 

When  acute  metritis  terminates  by  induration,  the  pain  and  fever 
diminish  gradually,  but  the  womb  loses  nothing  of  its  size,  density  or 
weight. 

The  termination  of  metritis  in  gangrene,  observed  by  several  cele- 
brated physicians,  as  by  Morgagni,  Lieutaud  and  Smellie,  is  preceded 
from  the  third  to  the  seventh  day,  by  vomiting,  hiccough,  comatose 
delirium,  and  constantly  increasing  meteorism;  the  alvine  evacuations 
become  involuntary,  black,  frequent,  and  of  a cadaverous  odour.  A 
discharge  of  fetid  matters  takes  place  from  the  vagina;  the  pain  and 
heat  cease  completely ; the  pulse  is  frequent,  very  small,  and  inter- 
mittent; finally,  convulsions,  syncope,  and  coldness  of  the  extremi- 
ties close  the  mournful  scene. 

In  cases  of  very  acute  metrilis,  speedily  terminated  by  death,  we 
find  portions  of  the  uterus  softened  and  converted  into  a kind  of 
liquid  and  sanious  putrescence,  which  seems  to  have  macerated  the 
parenchyma  of  the  organ.  At  other  times  the  viscus  is  more  or  less 
gangrenous,  and  its  cavity  contains  viscid  and  blackish  matters,  which 
exhale  a putrid  odour.  We  should,  however,  observe,  that  the  two 
last  symptoms  do  not  always  announce  gangrene  of  the  womb,  espe- 
cially when  the  metritis  has  occurred  soon  after  labour.  Indeed,  the 
black  colour  and  gangrenous  odour  of  the  substances  found  within 
the  uterus  after  death,  or  which  flow  from  the  vagina  during  life,  are 
often  due  to  the  putrefaction  of  the  placenta,  or  of  large  clots  of  blood, 
which  have  been  retained  in  the  cavity  of  the  womb.  Where  the 
disease  has  not  been  so  rapidly  fatal,  the  mucous  membrane  of  the 
womb  is  generally  very  much  thickened  and  of  a deep  red  colour ; 
the  tissue  of  the  organ  is  softened  and  engorged ; its  cavity  contains 
a bloody,  mixed  with  a sero-mucous  fluid,  which  gives  it  a sanious 
appearance,  and  which  escapes,  by  pressure,  from  the  uterine  paren- 

* Mauriceau,  Traite  des  Maladies  des  Femmes,  t.  ii.  observ.  254,  p.  211. 


282 


ACUTE  INFLAMMATION  OF  THE  WOMB. 


chyma,  as  from  a sponge.  These  changes  frequently  do  not  extend 
over  the  whole  of  the  viscus ; sometimes  they  are  seated  only  in  the 
neck,  and  at  other  times  in  the  fundus  and  on  the  interior  and  poste- 
rior paries.  The  tissue  of  the  healthy  portions,  ordinarily  pale, 
always  appears  thinner  and  denser  than  that  of  the  inflamed  portions. 
Finally,  it  happens  not  unfrequently  that  the  Fallopian  tubes,  the 
ovaries  and  the  parts  in  the  neighbourhood  of  the  womb,  participate 
in  the  disorders  of  which  it  is  the  point  of  departure  and  the  princi- 
pal seat. 

Where  metritis  terminates  in  resolution,  which  is  most  apt  to  oc- 
cur where  the  inflammation  is  of  small  extent  and  where  the  disease 
is  unconnected  with  delivery,  the  symptoms  gradually  become  less 
acute,  the  uterus  becomes  disengorged,  and  its  disengorgement  is 
assisted  and  made  evident  by  a sanguine  or  sero-mucous  discharge 
from  the  vagina.  It  is  then  of  the  utmost  importance  to  watch  the 
patient,  and  continue  for  some  time,  and  according  to  circumstances, 
therapeutic  and  hygienic  measures,  to  prevent,  as  far  as  possible,  the 
uterine  inflammation  from  passing  into  the  chronic  state.  Frequently 
women,  relieved  of  the  greater  part  of  their  sufferings,  and  supposing 
themselves  out  of  danger,  abandon  their  disease  to  the  efforts  of 
nature  alone,  and,  in  their  foolish  security,  often  partaken  by  their 
physician,  soon  pass  from  a cure  almost  complete,  to  a permanent 
pathological  condition,  constituting  the  chronic  metritis,  of  which  we 
shall  soon  have  to  speak. 

The  fortunate  termination  of  puerperal  metritis  is  also  preceded 
a diminution  of  the  symptoms,  but  particularly  by  the  re-appear- 
ance of  the  lochia,  the  swelling  of  the  mammae,  and  the  establish- 
ment of  the  milk  secretion.  When  metritis  attacks  during  preg- 
nancy, it  almost  inevitably  brings  on  premature  labour,  the  death  of 
the  foetus,  and  very  often  that  of  the  mother  also. 

The  diagnosis  of  acute  inflammation  of  the  uterus  is  often  rather  - 
obscure,  because  the  disorder  presents  symptoms  having  some 
analogy  to  those  of  peritonitis,  hysteria,  uterine  catarrh  and  acute 
cystitis.  When  the  inflammation  is  confined  to  the  neck  of  the 
womb,  the  symptoms,  usually  mild,  might  be  regarded  as  the  una- 
voidable consequences  of  a laborious  labour,  or  as  the  effects  of  a slight 
irritation  established  upon  the  os  tincae.  If,  on  the  contrary,  the  dis- 
ease extends  to  the  body  of  the  womb,  the  peritonitis,  which  very 
frequently  accompanies  it,  alone  attracts  the  attention  of  the  physi- 
cian, and  thus  prevents  him  from  attending  to  the  metritis,  whose 
existence  he  cannot  suspect.  When  the  inflammation  occupies  the 
uterus  and  peritoneum  at  the  same  time,  the  symptoms  of  metritis 
always  exist.  Though  they  may  be  veiled  by  those  of  the  peritonitis, 
it  will,  nevertheless,  be  possible,  with  a little  care,  to  discern  them. 

In  fact,  the  sensibility  of  the  neck  to  the  touch,  its  softness,  its  enlarge- 
ment, the  pain  produced  by  the  slightest  movement  communicated 
to  the  body  of  the  uterus,  and  the  spasm  propagated  towards  the  rec- 
tum and  bladder,  are  so  many  phenomena  which  are  absent  in  peri- 
tonitis, and  which  reveal  the  existence  of  an  acute  phlegmasia  ot  the 
gestative  organ.  Moreover,  in  peritonitis,  the  pain,  which  is  more 


ACUTE  INFLAMMATION  OF  THE  WOMB. 


283 


general  and  more  lacerating,  often  occupies  the  whole  abdomen,  and 
the  slightest  touch  exasperates  it  to  such  a degree,  that  not  only  is 
the  patient  unable  to  move  in  bed,  but  it  is  sometimes  impossible  for 
her  to  bear  the  contact  of  the  lightest  poultices,  or  even  that  of  the 
bed-clothes  or  of  a single  sheet.  In  metritis,  the  tension  of  the  abdo- 
men is  less  general,  and  the  pain,  which  seems  circumscribed  and 
seated  only  at  the  point  corresponding  to  the  uterus,  is  never  ac- 
companied by  expulsive  efforts,  which  are  proper  to  acute  inflamma- 
tion of  the  uterine  parenchyma. 

Acute  metritis  may  be  easily  distinguished  from  hysteria,  by  recol- 
lecting that  in  this  last  disease  pressure  upon  the  abdomen  does  not 
cause  pain,  that  the  abdomen,  far  from  being  tumid,  is  often  retracted, 
and  that  the  pulse  is  corded,  but  not  frequent;  finally,  that  the  pa- 
tient, whose  pains  are  irregular  and  whose  tongue  is  in  a natural 
condition,  always  feels  a sensation  of  strangulation  and  suffocation, 
produced  by  the  globus  hystericus  which  seems  to  arise  in  the -hypo- 
gastric region,  and  traverse  the  abdomen  and  thorax  to  be  arrested 
in  the  throat.  In  addition  to  the  symptoms  we  have  just  enumerated, 
we  should  not  forget  that  hysteria  is  a nervous  and  apyretic  affection, 
manifested  by  attacks  of  general  convulsion,  with  suspension,  more 
or  less  complete,  of  the  intellectual  faculties;  moreover,  the  Touch, 
which  affords  us  the  least  equivocal  signs  for  recognizing  metritis, 
teaches  us  also  that  in  hysteria  the  womb  is  generally  in  a healthy 
state. 

In  uterine  catarrh,  the  internal  membrane  of  the  uterus  is  alone 
affected;  the  inflammatory  phenomena  and  the  fever  are  moderate, 
the  pain  less  severe,  the  sensibility  of  the  Uterus  less  exalted,  and 
the  discharge  which  takes  place  by  the  vulva,  and  which  determines 
a sensation  of  tingling  in  urinating,  is  not  sanious  and  reddish,  like 
that  which  occurs  during  acute  metritis;  moreover,  the  facts  ascer- 
tained in  regard  to  the  invasion  of  the  disease  and  the  causes  which 
produce  it,  are  always  sufficient  to  establish  the  diagnosis. 

Acute  inflammation  of  the  uterus  may  easily  be  distinguished  from 
that  of  the  bladder,  if  we  reflect  that  in  the  latter  disease,  the  desire 
to  urinate  is  much  more  frequent  and  more  painful  than  in  metritis, 
and  that  it  is  necessary  to  make  violent  efforts  in  order  to  pass  a few 
drops  of  urine.  Most  commonly,  this  fluid  is  thick,  and  mixed  with 
mucus,  which  is  deposited  at  the  bottom  of  the  vessel  in  the  form 
of  a tenacious,  gluey  and  grayish  substance.  Cystitis  is  sometimes 
accompanied  by  other  more  serious  symptoms ; the  bladder  distended 
with  urine,  projects  above  the  pubis ; the  whole  abdomen  increases 
in  size  and  becomes  very  sensitive ; the  body  exhales  a distinct 
urinous  odour ; finally,  there  is  at  the  same  time  a sort  of  vesical 
tenesmus  with  painful  pruritus  in  the  urinary  meatus  and  constant 
factitious  desire  to  go  to  stool.  Therefore,  as  these  symptoms  are 
absent  in  acute  metritis,  it  becomes  impossible  to  confound  the  dis- 
ease with  inflammation  of  the  bladder. 

The  prognosis  of  acute  metritis,  which  is  generally  very  grave, 
depends  upon  the  extent  and  degree  of  intensity  of  the  inflamma- 
tion, its  co-existence  with  peritonitis,  or  with  any  other  complication, 


2S4 


TREATMENT  OP  ACUTE  METRITIS. 


on  the  more  or  less  advanced  period  of  the  disease,  or  the  effects  of 
the  first  therapeutical  means  employed ; finally,  on  the  age,  and  the 
constitution,  as  well  as  the  hygienic  condition  of  the  patient;  upon 
her  docility  in  following  the  advice  of  the  physician  ; the  season,  the 
prevailing  temperature,  the  epidemic  influences  and  the  circum- 
stances under  which  the  invasion  of  the  disease  has  taken  place. 
Other  things’  being  equal,  acute  inflammation  of  the  womb  is  most 
dangerous  during  gestation,  especially  when  developed  under  the 
influence  of  certain  epidemic  constitutions.  It  is  a disease  to  be 
dreaded,  not  only  because  it  often  produces  death,  but  likewise  be- 
cause, in  cases  where  women  attacked  with  it  fail  to  perish,  it  be- 
comes the  germ  of  other  diseases,  and  especially  of  chronic  metritis, 
which,  in  its  turn,  may  produce  ulceration,  degeneration  and  cancer 
of  the  uterus. 


TREATMENT  OF  ACUTE  METRITIS. 

The  treatment  of  acute  metritis  demands  certain  hygienic  precau- 
tions, which  cannot  but  augment  the  efficaciousness  of  the  therapeu- 
tical agents  that  we  are  about  to  treat  of. 

The  woman  should  be  kept  in  the  most  absolute  repose.  Her 
chamber,  which  ought  to  be  darkened  and  free  from  all  kinds  of 
emanations,  should  be  kept  at  a moderate  temperature,  and  iso- 
lated, as  much  as  possible,  from  whatever  might  disturb  the  moral 
and  physical  quietude.  The  air  should  be  frequently  renewed, 
with  the  precaution  that  no  current  be  directed  upon  the  patient. 
Mattrasses  of  wool  and  feather-beds  ought  to  give  place  to  hair- 
mattrasses,  and  if  the  weight  of  the  coverings  be  inconvenient  or 
painful,  we  may  prevent  their  contact  with  the  abdominal  parietes, 
by  means  of  hoops.  To  diminish  the  pain  by  keeping  the  abdomi- 
nal muscles  as  much  relaxed  as  possible,  the  patient  should  lie  upon 
her  back,  the  head  raised  and  flexed  by  means  of  pillows,  the  legs 
separated  and  the  thighs  flexed  with  the  aid  of  cushions.  Finally, 
we  should  remove  all  the  causes  capable  of  producing  a vivid  moral 
or  physical  impression  upon  the  patient,  and  especially  we  should 
remove  all  persons  that  might  vex  or  injure  her  by  reporting  bad 
news. 

Acute  metritis,  like  all  other  inflammations,  must  be  combated 
by  the  most  vigorous  antiphlogistics  ; in  general  it  is  necessary,  from 
the  beginning,  to  have  recourse  to  general  and  local  bleedings  not- 
withstanding the  smallness  of  the  pulse,  for,  in  proportion  as  the 
blood  flows,  the  pulsations  rise  and  become  more  developed.  Though 
all  the  ancient  and  modern  authors  agree  upon  the  necessity  of  san- 
guine evacuations,  they  are  not  of  the  same  opinion  as  to  the  choice 
of  bleeding  from  the  arm  or  from  the  foot.  Amongst  the  ancients, 
Galen,  Oribasius,  iEtius,  etc.,  and  amongst  the  moderns,  Mauriceau, 
Dionis,  and  Astruc,  as  well  as  almost  all  the  practitioners  of  our 
own  day,  give  the  preference  to  bleeding  from  the  arm,  while  Mercu- 
rialis,  Hoffman  and  some  others,  advise  bleeding  from  the  foot, 
which  is  also  recommended  by  Pasta,  always  preceded,  however,  by 


TREATMENT  OF  ACUTE  METRITIS. 


285 


that  from  the  arm.  If  the  disease  have  not  been  caused  by  suppres- 
sion of  the  menstrual  flow,  bleeding  from  the  arm  is  alone  indicated; 
in  the  contrary  case,  we  might  advantageously  open  the  veins  of  the 
inferior  extremities,  and  then  resort  to  applications  of  leeches  to  the 
vulva,  and  to  the  superior  and  internal  surfaces  of  the  thighs:  as  a 
general  rule,  bleeding  in  the  brachial  veins  should  be  preferred,  either 
because  it  is  of  easier  performance,  because  we  can  take  more  blood 
in  less  time,  and  from  its  being  more  certain;  or  else  because  we  can 
better  appreciate  the  quantity  of  blood  obtained,  and  from  its  being 
less  incommodious  to  the  patient,  whom  it  is  unnecessary  to  uncover 
and  whom  we  are  not  forced  to  move,  which  always  increases  her 
sufferings. 

After  general  bleeding,  which  we  should  not  fear  to  repeat,  though 
the  pulse  is  often  small  and  frequent,  it  is  proper  to  resort  to  capil- 
lary and  local  bleeding,  by  means  of  leeches  applied  to  the  vulva, 
to  the  inguinal  and  hypogastric  regions,  to  the  anus,  and  even  over 
the  whole  abdomen,  if  the  metritis  were  complicated  with  peritonitis, 
which  often  happens.  Scarified  cups  upon  the  mammae,  the  loins,  or 
the  hypogastrium  and  to  the  thighs,  are  likewise  indicated. 

At  the  same  time  the  hypogastrium  should  be  covered  with  emol- 
lient applications,  and  particularly  with  fomentations  made  with 
flannel  dipped  in  a decoction  of  flax-seed  and  poppy-heads.  Demul- 
cent and  narcotic  injections  into  the  vagina  should  also  be  prescribed, 
as  well  as  small  enemata  of  the  same  nature,  absolute  repose,  rigor- 
ous diet,  gummy  and  cooling  drinks,  and  in  due  time  veal  broth, 
whey,  almond  emulsion,  and  sometimes  slightly  laxative  or  diu- 
retic tisans.  The  pulp  of  tamarinds,  and  dog-grass  with  nitre,  fulfil 
very  well  the  two  last  indications.  If  the  pain  be  extremely  severe, 
we  should  order  a sedative  potion,  and  insist  upon  injections  of  the 
same  nature ; flying  sinapisms  and  blisters  placed  upon  different 
points  of  the  surface  of  the  body,  are,  after  the  use  of  depletion,  usually 
advantageous,  because  they  recall  the  blood  and  vital  forces  from 
the  centre  to  the  extremities.  The  drawing  of  the  breasts,  in  recently 
delivered  women,  or  the  application  of  cups  to  these  organs,  irritate 
and  excite  in  a very  efficacious  manner  the  derivative  movement 
which  we  are  seeking  to  provoke.  Although  it  seems  as  though  we 
might  obtain  good  results  also  from  general  baths,  we  think  that 
they  ought  to  be  rejected  in  the  greater  number  of  cases,  because, 
independently  of  the  frighful  suffering  which  the  patient  undergoes 
in  the  removal  to  the  bath,  there  often  arise  dangerous  conse- 
quences from  the  action  of  the  air  on  the  skin,  or  perhaps  from  the 
difficult  adjustment  of  a suitable  temperature.  As  a substitute  for 
the  bath,  and  to  avoid  perspiration,  Chaussier  recommended  the 
introduction  of  the  vapour  of  water  into  the  bed,  by  means  of  a 
tin  tube.  The  coverings  should  first  be  raised  up  by  means  of 
a hoop.  If,  after  the  active  and  well-directed  application  of  all  these 
means,  the  womb  still  remains  tumefied  and  engorged,  although  the 
general  phenomena  and  acute  local  symptoms  have  in  part  disap- 
peared, we  can  assist  and  almost  always  obtain  a resolution  of  the 
disease,  by  means  of  frictions  with  tartar-emetic  ointment  first  to 


286 


TREATMENT  OF  ACUTE  METRITIS. 


the  internal  part  of  the  thighs,  then  to  the  sides  of  the  trunk,  and 
finally  upon  the  abdominal  parietes.  This  method,  which  was  recom- 
mended and  employed  with  much  success  by  M.  Duparcque,  has 
been  used  by  us  for  a long  time,  not  only  in  the  same  circumstances 
as  by  the  excellent  practitioner  of  whom  we  have  just  spoken,  but 
also  in  the  treatment  of  different  affections  of  the  vocal  organs.* 

The  diseases  which  sometimes  complicate  acute  metritis,  ought  to 
lead  to  great  modifications  in  the  treatment.  Thus,  in  the  case  of 
complication  of  a bilious  or  gastric  kind,  we  should  be  more  careful 
in  our  employment  of  bleeding,  and  it  will  be  useful  to  administer 
emetics  of  ipecacuanha,  followed  by  some  mild  laxative,  especially 
when  the  disease  is  attended  with  obstinate  constipation.  If  typhoid 
and  adynamic  symptoms  occur  in  the  course  of  the  metritis,  it  would 
be  necessary,  after  having  used  with  circumspection,  and  to  a mode- 
rate extent,  some  sanguine  evacuation,  to  resort  to  the  use  of  topical 
remedies,  and  then  to  derivatives,  especially  blisters  ; finally,  in  case 
nervous  and  ataxic  symptoms  make  their  appearance,  we  Should 
prescribe  antispasmodics  and  narcotics. 

When  metritis  terminates  by  suppuration,  it  is  necessary  to  open 
in  good  time  the  abscesses  accessible  to  light  and  touch,  in  order  to 
avoid  the  purulent  collections  which  might  form  in  the  abdomen ; 
if  the  pus  had  opened  into  the  uterine  cavity,  the  vagina,  the  rectum 
or  the  bladder,  we  should  throw  injections  into  these  cavities,  at  first 
emollient,  and  then  gently  detergent.  In  case  the  metritis  should 
terminate  by  gangrene,  it  would  be  necessary  to  suspend  the  anti- 
phlogistics,  and  have  recourse  to  antiseptics  and  tonics,  which  should 
be  simultaneously  administered  in  drink,  in  fomentations,  in  injections 
and  in  enemata. 

[I  regret  that  M.  Colombat  should  have  separated  the  discussions  on  the 
subject  of  acute  metritis,  from  those  that  will  be  found  in  a subsequent  one 
on  puerperal  fever,  since  it  is  desirable,  in  order  to  enjoy  a good  coup-d’oeil 
of  the  whole  subject,  to  have  them  as  nearly  approximated  as  possible,  thus 
preserving  a sort  of  natural  order  in  the  arrangement  of  these  so  frequently 
coincident,  if  not  identical  affections.  As  I propose  to  make  some  remarks 
on  the  subject  of  puerperal  fever,  when  that  topic  shall  have  been  reached 
in  the  course  of  this  publication,  I shall,  for  the  sake  of  avoiding  iterations, 
postpone  any  remarks  that  I may  have  for  that  occasion,  and  I accordingly 
refer  the  reader  to  that  portion  of  this  work,  merely  stating  that  the  valuable 
labours  of  Robert  Lee,  of  London,  in  his  treatise  on  the  subject,  may  he 
found  in  a volume  published  in  1842,  here,  in  Bell’s  Library,  where  it  is 
accompanied  by  the  previous  tracts  of  Gordon,  Hey  of  Leeds,  and  John 
Armstrong,  on  the  same  topic. 

There  is  an  affection  of  women,  of  no  small  importance,  and  not  (infre- 
quently met  with  in  practice,  which  has  wholly  escaped  the  attention  of 
M.  Colombat.  The  disease  to  which  l allude  is  rheumatism  of  the  womb, 

* Our  opinions  upon  this  point  were  expressed  in  our  treatise  upon  the  diseases  of 
the  organs  of  voice,  published  some  years  since. 


RHEUMATISM  OF  THE  WOMB. 


28  7 


concerning  which  not  much  has  been  as  yet  published.  Neither  Moreau  nor 
Chailly,  among  the  latest  of  the  French  system  writers  on  Midwifery,  having 
Said  any  thing  about  it,  except  a very  meagre  allusion  to  the  disorder  by 
Chailly,  at  p.  717.  The  elegant  and  valuable  treatise  on  Midwifery,  by  M. 
Cazeaux,  which  came  out  in  1840,  has  a tolerably  full  account  of  it,  in 
Chap.  6th,  at  p.  646,  of  the  Traite  Theorisque  et  Pratique  de  VArt  des 
Accouchements , 8vo.  Paris,  1840,  p.  836,  with  plates.  As  Mons.  Ca- 
zeaux’s  article  is  a very  sensible  and  discreet  one,  and  presents  a description 
of  the  malady  in  accordance  with  my  own  experience  at  the  bed-side,  I shall 
think  that  the  value  of  this  publication  will  be  enhanced  by  transferring  to 
these  pages,  the  whole  of  his  article  on  rheumatism  of  the  womb. 

“ Rheumatism  of  the  womb,”  says  M.  C.,  “after  having  long  attracted  the 
attention  of  the  German  practitioners,  was  but  little  known  in  France,  when 
M.  Dezeimeris,  in  his  journal,  (V Experience,)  made  public  a series  of  facts 
already  known  and  published  by  certain  German  authors.  About  the  same 
time,  M.  Stolz,  who  had  become  acquainted  with  the  labours  of  our  neigh- 
bours on  this  subject,  studied  the  affection  at  the  Clinical  Hospital  at 
Strasburg,  and  communicated  the  results  of  his  researches  to  his  pupils. 
One  of  these  gentlemen,  Dr.  Salathe,  has  very  recently  defended  a thesis  on 
this  topic.  To  his  work,  and  to  the  bibliographical  researches  of  M.  Dezei- 
meris I am  indebted  for  what  I am  about  to  say  upon  this  disorder,  which 
is  hitherto  unknown  to  our  French  nosologists. 

“ According  to  Radamel,  rheumatism  may  attack  the  non-gravid  womb  ; 
but  our  business  here  is  to  study  it  only  as  occurring  in  pregnant  women. 
It  may  attack  at  any  stage  of  gestation,  and  we  shall,  therefore,  after  some 
general  considerations  on  the  subject,  point  out  the  influence  it  may  exert  in 
pregnancy,  in  labour,  and  in  the  lying-in. 

“ Causes. — All  such  circumstances  as  are  favourable  to  the  development 
of  rheumatic  affections,  may  likewise  lead  to  an  attack  of  rheumatism  of  the 
womb.  Thus  exposure,  whether  momentary  or  prolonged,  to  dampness 
and  cold,  insufficient  clothing,  sudden  transposition  from  an  elevated  to  a 
very  low  temperature,  and  all  other  causes,  constitutional  and  atmospheric, 
regarded  by  medical  authors  as  occasional  or  predisposing  causes  of  rheu- 
matism, may  also  produce  that  of  the  uterus.  But,  besides  these  general 
causes,  there  is  one  peculiar  to  the  malady  under  consideration.  I allude  to 
the  facility  with  which  this  organ,  under  the  thinned  integuments  of  the 
abdomen,  feels  the  impression  of  cold  in  the  latter  months  of  pregnancy; 
the  abdomen  being  guarded,  when  it  encloses  the  uterus  by  extremely  light 
garments,  which  are  closely  in  contact  with  it,  and  the  antero-sacral  region 
being  often  badly  protected  by  jackets  of  insufficient  length. 

“ Symptoms. — Rheumatism  of  the  womb  often  attacks  persons  consti- 
tutionally predisposed  to  nephritis.  It  may  coexist  with  a general  affection 
of  the  same  nature;  but,  in  a majority  of  cases,  the  uterus  alone,  and  the 
adjacent  structures,  are  the  seats  of  the  disorder.  It  has,  besides,  been  fre- 


288 


RHEUMATISM  OF  THE  WOMB. 


quently  found  to  be  a consequence  of  the  sudden  cessation  of  rheumatic 
pain,  originally  situated  in  some  other  part,  and  suddenly  transposed  to  the 
womb.  Whatever  may  be  the  mode  of  its  onset,  the  disorder  is  easily 
recognized  by  very  decided  characteristic  features.  Its  principal  symptom 
is  pain,  where  not  the  least  violence  has  been  offered  to  the  organ,  the  womb 
becomes  the  seat  of  a general  or  partial  pain,  the  intensity  of  which  varies 
from  the  very  slightest  sense  of  weight  up  to  the  most  insupportable  agony. 
It  may  affect  the  uterus  wholly,  or  only  attack  some  particular  part  of  it,  as 
the  orifice,  the  fundus,  or  the  cervix.  Where  the  rheumatism  is  fixed  in  the 
fundus  only,  the  pain  is  felt  in  the  region  above  the  umbilicus.  It  is  in- 
creased by  pressure,  by  the  contraction  of  the  abdominal  muscles,  and  some- 
times by  the  mere  weight  of  the  clothes ; the  patient,  often,  is  unable  to 
move ; if  the  disorder  is  seated  lower  down,  there  are  shooting  pains  that 
run  from  the  loins  towards  the  pelvis,  the  thighs,  the  external  genitals,  and 
the  sacral  region,  along  the  ligaments  of  the  uterus.  Lastly,  when  the 
cervix  is  the  affected  part,  it  may  be  known  by  the  vaginal  touch  which 
gives  rise  to  excessive  suffering.  But  of  all  the  causes  that  serve  to  exas- 
perate the  pain,  none  is  so  distressing  as  the  incessant  motions  of  the  child. 

“ Like  other  rheumatic  pains,  those  of  the  womb  are  movable,  and  are 
observed  occasionally  to  pass  suddenly  from  one  portion  of  the  organ  to 
another.  They  often  suddenly  cease,  and  proceed  to  attack  some  other 
organ.  This  is  most  apt  to  happen,  where  the  uterine  rheumatism  has 
been  preceded  by  a fixed  pain  of  some  other  part  of  the  body,  and  where 
remedies  are  in  use  calculated  to  recall  the  pain  to  its  original  seat. 

“ These  pains  are  characterized  by  frequent  exacerbations  that  are 
variable  as  to  their  duration  and  intensity ; according  to  the  stage  of 
the  malady,  they  are  succeeded  by  remissions,  during  which  the  patient 
scarcely  complains  of  a vague  sense  of  weight. 

“ The  pains  of  uterine  rheumatism  are  generally  attended  with  a degree 
of  recto-vesical  tenesmus,  which  is  violent  in  proportion  to  the  severity  of 
the  pains  and  the  approximation  of  the  seat  of  the  rheumatism  to  the 
lower  segment  of  the  organ.  In  such  cases,  the  patient  is  tormented  by 
perpetual  desire  to  urinate.  The  discharge  of  the  urine  is  accompanied 
with  smarting  pain,  sometimes  with  severe  pains,  and  in  some  instances 
the  discharge  cannot  be  effected  at  all ; the  efforts  to  discharge  the  contents 
of  the  rectum  are,  in  some  cases,  equally  fruitless.  Most  of  the  German 
authors  attribute  this  double  recto-vaginal  tenesmus  to  the  rheumatic  dis- 
ease, which  is  not  always  confined  strictly  to  the  uterus  alone,  but  may 
likewise  invade  the  circumjacent  organs.  M.  Stolz  seems  disposed  to 
think  that  it  arises  from  the  close  sympathetic  relations  of  parts  so 
nearly  approximated  to  each  other.  Should  these  new  pains  be  owing  to 
a vesical  or  rectal  rheumatism,  those  of  the  womb  would  disappear,  or  at 
least  be  diminished  in  degree,  according  to  the  views  of  M.  Salathe  in  his 
Thesis. 


RHEUMATISM  OF  THE  WOMB. 


289 


“ It  is  to  be  supposed  that  there  is  a degree  of  heat  and  swelling  of  the 
affected  parts;  but  it  is  easy  to  perceive  the  difficulty  of  absolutely  deter- 
mining this  point,  one  which  we  are  compelled  to  admit  from  analogy. 

“Pains  of  such  violence,  situated  in  an  organ  so  important,  must  of 
necessity  produce  a pretty  severe  general  reaction.  The  disorder,  like  most 
of  the  inflammatory  diseases,  generally  commences  with  a slight  rigor, 
which  lasts  fifteen  or  twenty  minutes.  The  succeeding  fever  diminishes, 
or  may  even  wholly  cease  during  the  interval  between  the  attacks,  yet 
while  they  last  it  is  commonly  quite  severe;  the  pulse  is  hard  and  fre- 
quent, the  face  flushed  and  excited,  the  tongue  red  and  dry,  the  thirst 
urgent;  the  skin  is  hot,  and  the  patient  is  often  found  to  be  extremely 
agitated  and  restless.  Towards  the  close  of  the  paroxysm,  there  fre- 
quently supervenes  a copious  sweat,  which  seems  to  be  the  harbinger  of  a 
decided  improvement.  After  this,  these  general  symptoms  are  appeased, 
together  with  the  uterine  pains,  only  to  reappear  with  them,  after  the  lapse 
of  a few  hours,  or  even  of  several  days. 

“ 1st.  Influence  of  Rheumatism  on  the  progress  of  Pregnancy. — Where 
the  attacks  may  have  persisted  for  a length  of  time,  or  where  they  have 
been  very  violent,  they  are  followed  by  uterine  contractions,  and  may,  in 
this  way,  bring  on  premature  delivery.  In  such  a case  the  patient  suffers 
from  severe  tensive  pain.  This  feeling  of  tension  is  not  equable,  for  it  rises 
to  a great  height,  and  then  subsides — to  begin  again  and  pursue  the  same 
course  at  different  intervals.  At  first  the  womb  becomes  partially,  and 
afterwards  universally  hardened  during  the  pain.  The  cervix  becomes 
rigid  and  partially  dilated,  but  its  dilatation  is  at  first  slow  and  difficult,  and 
its  subsequent  progress  does  not  correspond  with  the  pace  of  the  pains. 
The  abortion,  with  which  she  is  now  menaced,  is  more  likely  to  take  place 
in  the  febrile  than  in  the  apyretic  form  of  rheumatism.  Indeed,  abortion 
is  not  so  common  an  occurrence  in  the  case  as  might  be  presumed.  In 
some  instances  the  os  uteri  has  been  observed  to  dilate  to  the  extent  of  two 
or  three  centimeters  in  diameter,  the  bag  of  waters  has  been  formed,  and 
afterwards  withdrawn  little  by  little,  the  orifice  closing  again,  and  all  symp- 
toms of  labour  wholly  to  disappear.  As  long  as  the  diameter  of  the  os 
uteri  does  not  reach  the  extent  of  five  centimeters,  we  may  reasonably 
hope  to  put  off  the  labour.  These  uterine  rheumatic  pains  may  simulate 
labour  pains,  and.  lead  to  the  belief  that  they  are  really  labour  pains, 
while  in  fact  they  are  not  at  all  so.  The  characteristic  signs  of  the  rheu- 
matic pains,  given  in  the  following  paragraph,  should  serve  to  prevent 
such  a mistake.  It  is  surely  to  mistakes  of  this  kind,  that  we  ought  to 
refer  those  cases  of  supposed  protracted  pregnancy,  and  those  instances  of 
real  labour,  begun,  and  suspended  again  for  weeks  and  even  for  months 
together.” 

On  the  29th  January,  1842,  Mrs.  0.,  aged  twenty-eight,  in  her  first  preg- 
nancy eight  and  a half  months,  was  suffering  with  the  symptoms  of  severe 

19 


290 


RHEUMATISM  OF  THE  WOMB. 


rheumatism  of  the  womb,  which  had  afflicted  her  since  about  the  12th  of 
the  month.  On  the  15th  of  the  month,  fearing  that  labour  was  begun,  I 
examined  and  found  the  os  uteri  dilated  fully  a quarter  of  an  inch,  and  the 
cylindrical  tubule  of  the  cervix  wholly  gone;  but  on  the  29th  of  the  month, 
or  fourteen  days  later,  during  all  which  time  she  suffered  more  or  less,  the 
os  uteri  was  not  only  closed  up,  but  the  cylindrical  tubule  of  the  cervix  was 
reproduced,  and  continued  so  until  her  child  was  born  on  the  1 6th  day  of 
February. 

About  three  years  since,  a lady,  a missionary,  landed  here  from  a voyage 
from  Madras,  of  one  hundred  and  twenty  days.  She  walked  a good  deal 
on  the  day  of  her  debarkation,  and  was  seized  with  the  signs  of  labour  the 
same  evening,  being  not  quite  eight  months  gone  with  child.  The  pains 
were  strong;  I found  the  os  uteri  an  inch  and  a half  in  diameter,  with  the 
membranes  tensely  drawn  across  the  opening.  The  labour  was  suspended 
in  the  night,  but  returned  again  the  next  afternoon  ; and  during  twenty-four 
days  that  she  continued  to  be  annoyed,  more  or  less,  with  signs  of  labour, 
the  os  uteri  never  closed,  and,  at  the  end  of  that  time,  she  gave  birth  to  a 
small,  but  healthy  male  child.  I have  had  many  occasions  to  see  persons 
threatened  with  labour,  and  even  precipitated  into  it,  by  rheumatism  of  the 
womb. 

M.  Cazeaux  says  nothing  of  the  diagnosis,  which  I regard  as  one  among 
the  most  difficult  that  can  be  presented  to  the  mind  of  a physician.  To 
make  the  diagnosis  between  pleurisy  and  pleurodyne,  is  often  a very  diffi- 
cult task,  and  one  of  considerable  moment,  too ; but,  to  make  out  satisfac- 
torily all  the  points  of  difference  betwixt  rheumatism  of  the  womb  and  the 
acute  inflammations  of  the  organ,  especially  in  the  lying  in,  is  still  more  mo- 
mentous. Rheumatism  is,  so  far  as  my  experience  of  it  enables  me  to  speak, 
most  apt  to  attack  very  nervous  and  susceptible  women  who  have  become 
weakened  and  reduced  in  strength,  from  whatever  cause.  In  such  subjects, 
it  is  highly  desirable  to  get  through  the  case  without  much  resort  to  the 
stronger  antiphlogistic  measures;  but,  if  we  mistake  an  intense  metro-peri- 
tonitis for  a case  of  rheumatism  of  the  uterus,  we  shall  abstain  from  any 
vigorous  and  eradicative  employment  of  the  lancet,  pnder  the  vain  hope  of 
curing  our  patient  by  milder  and  less  costly  processes  than  the  exhausting 
venesections  which  are  so  indispensable  in  the  true  inflammation. 

I have  had  such  great  difficulty  in  settling,  to  the  satisfaction  of  my  own 
judgment,  the  diagnostic  differences  betwixt  the  two  maladies,  in  several 
violent  cases  that  have  fallen  under  my  notice,  within  a few  years,  that 
I should  be  thankful  for  the  indication  of  a clear  method  of  coming  to  the 
decision.  In  both  maladies  is  the  fever  often  violent;  in  rheuraatismus 
uteri  there  is  rheumatic  neuralgia  of  other  parts,  and  a preceding  history, 
that  may  enlighten  the  practitioner  to  his  decision.  In  the  two  diseases 
there  is  equal  sensibility  of  the  abdomen ; meteorismus  may  accompany 
both.  The  heat  of  skin,  and  frequency  and  volume  of  the  pulse,  are  alike 


RHEUMATISM  OF  THE  WOMB. 


291 


in  each — the  decubitus  similar;  but  the  tongue  is  clean,  so  far  as  I have 
noticed  it  in  the  rheumatic  case.  Distracted  with  the  uncertainty  and  doubt 
in  which  the  case  is  involved,  I have  commonly  been  able  to  satisfy  my 
mind  by  a direct  appeal  to  the  organ  itself,  in  the  operation  of  Touching. 
In  both  maladies,  the  Touch  is  at  first  painful ; in  metritis  and  metro-perito- 
nitis, it  is  so  under  all  circumstances  ; but,  in  rheumatismus  uteri*  though 
the  first  touch  of  the  womb  is  painful  and  quick , yet  when  the  organ  is 
gently  and  slowly  raised  upwards  with  the  index  and  medius,  the  pain 
either  ceases  wholly  or  is  much  mitigated,  by  taking  off,  in  this  way,  the 
tenesmus  uteri ; not  so  in  the  inflammation,  where  every  touch  is  more  pain- 
ful the  more  it  is  prolonged.  I may  be  permitted  to  add,  that  I have  heard 
of  several  cases  of  death  from  puerperal  fever,  where,  upon  an  autopsy,  not 
the  least  vestige  of  inflammation  was  discovered,  either  in  the  peritoneum, 
the  uterine  veins,  the  substance  of  the  uterus,  or  any  of  its  appendages.  Is 
it  uncharitable  to  suppose  that  such  patients  died,  not  with  the  malady  for 
which  they  were  treated,  but  with  another  disorder,  to  wit,  rheumatismus 
uteri,  which  demanded  quite  a different  mode  of  cure?*  but  I fear  to  extend 
this  note  too  far,  and  therefore  M.  Cazeaux  proceeds  as  follows : M. 

“2 d.  Influence  of  Rheumatism  upon  Labour. — An  attack  of  uterine 
rheumatism  generally  retards  the  progress  of  a labour,  and  sometimes 
even  renders  the  spontaneous  expulsion  of  the  foetus  wholly  impos- 
sible. In  addition  to  the  general  phenomena  I have  described,  there  are 
here  some  special  ones  to  be  met  with.  1st.  It  is  well  known  that  a normal 
contraction  does  not  begin  to  be  painful  until  it  has  accomplished  the  greater 
part  of  its  task,  and  is  in  the  act  of  dilating  and  distending  the  os  uteri ; in 
other  words,  the  true  pains  of  labour  do  not  begin  until  the  instant  at  which 
the  energy  of  the  corpus  uteri  begins  to  overcome  the  resistance  of  the  cervix. 
In  rheumatism  of  the  womb,  on  the  other  hand,  the  uterine  contraction 
begins  to  be  painful  from  the  start,  and  before  the  least  power  is  exerted  on 
the  neck;  so  that  the  cause  of  the  pain  is  not  in  the  violent  distension  of 
the  orifice,  but  in  the  contraction  itself,  in  other  morbid  circumstances,  and 
in  other  relations  of  the  nerves  and  contractile  fibres  of  the  womb.  2d.  In 
a natural  labour,  the  contractions  commence  at  the  fundus  uteri,  and  are 
directed  towards  the  lower  segment.  In  rheumatism,  instead  of  commencing 
at  the  fundus,  they  commence  at  the  painful  point,  and  run  towards  the  neck 
in  an  irregular  manner.  Again,  the  pains  exist  before  the  contractions  of 
the  womb  ; and,  under  their  influence,  when  they  are  established,  acquire  a 
high  degree  of  intensity.  Their  violence  sometimes  arrests  the  contractions 

* M.  Cazeaux  himself,  near  the  end  of  this  article,  says  that  it  is  often  liable  to  be 
mistaken  for  a pure  inflammation,  and  then  treated  by  remedies  more  likely  to  be 
injurious  than  beneficial.  If  it  be  true  that  the  danger  to  life  from  rheumatismus 
uteri  be  but  small,  as  Mr.  C.  supposes,  it  is  at  least  dangerous  when  improperly 
treated  under  a false  apprehension  of  its  dangerously  inflammatory  and  destructive 
character. 


292 


RHEUMATISM  OF  THE  WOMB. 


before  they  have  run  through  their  ordinary  cycle.  They  are,  in  such  a 
case,  brisk,  short,  and  grow  less  and  less  frequent.  3d.  Towards  the  close 
of  the  labour,  when  the  action  of  the  womb  requires  to  be  sustained  by  the 
voluntary  contraction  of  the  abdominal  muscles,  the  woman,  for  fear  of  in- 
creasing her  sufferings,  refrains  from  contracting  her  abdominal  muscles, 
which  causes  the  labour  to  be  excessively  slow.  The  patient  is  in  a state  of 
extreme  anxiety ; the  frequent  pulse,  the  hot  skin,  the  thirst,  the  urinary 
tenesmus,  are  much  augmented.  When  the  sufferings  are  too  much  pro- 
tracted, she  at  last  falls  into  a collapse,  (which  is  often  a fortunate  event  for 
her;)  during  which  the  pain  is  suspended.  Under  these  circumstances,  a 
profuse  sweat  has  been  observed,  which  has  had  the  happiest  effect  on  the 
rest  of  the  labour.  But,  in  other  instances,  the  womb  grows  more  and  more 
painful ; it  is  rather  in  a state  of  permanent  contraction,  or  fibrillar  vibration, 
than  of  real  contraction;  the  pulse  becomes  accelerated,  and  now  the  woman 
is  under  the  influence  of  a metritis  which  renders  the  labour  extremely 
painful. 

“3d.  Influence  of  Rheumatism  of  the  Womb  on  the  puerperal  func- 
tions.— One  may  conceive,  d priori , that  uterine  rheumatism,  by  causing 
irregular  or  partial  contractions  of  the  organ  immediately  subsequent  to  the 
birth  of  the  child,  might  be  the  occasion  of  much  difficulty  in  the  delivery  of 
the  placenta  ; hut  this  is  not  the  place  to  discuss  that  point. 

“ In  health,  after  the  delivery,  the  womb  contracts,  and  thus  prevents 
haemorrhage.  But  in  rheumatism  this  return  of  the  organ  is  very  incom- 
plete ; it  remains  above  the  pubis  and  is  large.  The  after-pains  are  now 
very  painful,  and  continue  for  a long  time.  The  uterine  vessels  are  less 
compressed,  whence  may  arise  very  copious  floodings.  On  the  other  hand, 
the  state  of  suffering  in  which  the  organ  is  placed  diminishes  the  lochial 
discharge,  and  the  secretion  of  milk.  The  persistence  of  abdominal  pain, 
added  to  the  symptoms  of  a general  reaction,  might  lead  to  the  diagnosis  of 
a peritoneal  inflammation,  though  none  such  should  really  exist. 

“ Prognosis . — Rheumatism  of  the  womb  is  not  a disease  capable  of  caus- 
ing the  loss  of  the  mother’s  life;  but  from  the  pain  it. occasions,  and  the 
mistakes  to  which  it  leads,  it  nevertheless  merits  all  the  attention  of  the 
physician.  In  pregnancy,  it  may  cause  abortion ; and  though  it  does  not 
generally  exhibit  itself  until  the  sixth  month,  it  is  always  unfortunate  for  the 
child  to  be  born  before  full  term.  We  have  already  remarked  upon  the 
unfavourable  effect  produced  by  the  disorder  on  the  course  and  character  of 
labour-pains.  On  many  occasions  it  has  led  to  the  necessity  of  artificial  de- 
livery. It  may  likewise  render  the  delivery  of  the  after-birth  difficult,  and 
derange  the  course  of  the  phenomena  that  ought  naturally  to  follow  after 
the  birth  of  the  child.  At  this  period  it  is  often  confounded  with  phenomena 
that  are  purely  inflammatory,  and  is  then  treated  by  measures  that  are  hurt- 
ful rather  than  beneficial. 

“The  disorder  is  for  the  most  part  less  favourable  when  attacking  at  an 


CHRONIC  METRITIS. 


293 


early  than  at  a late  period  of  gestation  ; because  it  has  a more  unfavourable 
influence  on  the  progress  of  the  gestation  as  yet  incompletely  established 
and  settled ; and  also  because  it  lias  a tendency  to  be  reproduced  again  and 
again  before  the  completion  of  the  term,  and  on  account  of  its  disposition 
to  return  during  the  labour,  which  it  is  apt  to  render  laborious. 

“ Treatment. — 1st.  During  pregnancy,  blood-letting,  intestinal  revulsives 
(ipecac.,  castor  oil)  baths,  opiated  lotions  for  the  abdomen — anodyne  potions, 
sudorific  drinks.  Such  are  the  measures  which  have  been  most  constantly 
successful.  In  cases  where  the  affection  of  the  uterus  had  followed  the 
sudden  disappearance  of  a rheumatic  pain  of  some  other  part,  revulsives 
should  be  applied  to  the  part  first  affected.  2d.  During  labour,  the  same 
means  are  applicable  ; should  they  fail,  and  the  os  uteri  as  to  its  dilatation 
admit  of  it,  let  the  delivery  be  effected  by  means  of  turning  or  the  forceps. 
3d.  After  delivery,  sudorific  drinks,  anointing  the  abdomen  with  opiated 
ointments,  baths,  leeches  to  the  vulva,  and  when  the  lochial  discharge  has 
failed,  ipecac,  and  opium  combined.” 

✓ 

OF  CHRONIC  METRITIS  OR  SUBACUTE  INFLAMMATION  OF  THE 
PROPER  TISSUE  OF  THE  UTERUS. 

Of  all  the  diseases  to  which  women  are  exposed,  there  is  none 
more  common,  or  more  apt  to  be  misunderstood  than  chronic  inflam- 
mation of  the  womb.  This  affection,  not  in  itself  very  dangerous, 
is  nevertheless  often  followed  by  the  most  unfortunate  results,  because 
persons  who  are  attacked  with  it,  guided  by  a sense  of  natural,  but 
unreasoning  modesty,  put  off  consulting  the  physician  until  their 
sufferings  and  inconveniences  become  altogether  insupportable,  and 
sometimes  even  until  the  march  of  their  disease  has  placed  it  beyond 
the  resources  of  art. 

This  affection,  like  acute  inflammation  of  the  uterus,  may  occupy 
the  whole  of  the  organ  or  be  confined  to  the  neck,  and  in  the  same 
way  may  succeed  to  acute  metritis,  or  declare  itself  primarily  in  the 
chronic  state.  These  observations  upon  the  seat  and  etiology  of 
uterine  inflammations,  had  already  been  made  by  the  ancients ; for, 
in  speaking  of  the  disease  which  now  engages  us,  JEtius*  expresses 
himself  in  the  following  manner:  « Uterus  interdum  millo  prius 
indicant e signo  repent e induratur  ” and  Paul  of  Egina,  who 
copied  a part  of  the  works  of  Alexander  Traliianus,  and  who  was 
of  great  authority  amongst  the  Arabian  physicians,  says  also : 
“ In  scyrrhum\  induratur  uterus  aliquando  derepente  mulla 
praegressd  enusd 

When  chronic  inflammation  of  the  womb  follows  acute  metritis, 
it  recognizes  the  same  causes  ; when,  on  the  contrary,  it  is  primitive, 
it  results  from  special  causes,  which  we  shall  divide  into  predisposing 

* Contracts  ex  veter.  Tetrab.,  lib.  xvi.cap.  86. 

f De  Medic.,  lib.  xxiii.  cap.  64.  Paul  of  Egina,  (loc.  cit.)  arid  H3tius,  (loc.  cit.)  de- 
signate chronic  inflammation  of  the  body  of  the  womb  by  the  word  Scyrrhus,  and 
that  of  the  neck  of  this  organ,  by  the  term  Selcroma. 


294 


CHRONIC  METRITIS. 


and  exciting.  Among  the  former,  we  should  include  depressing 
moral  affections,  a lymphatic  temperament,  scrofulous  childhood, 
herpetic  or  syphilitic  diathesis,  cancerous  hereditation,  bad  alimenta- 
tion, dwelling  in  a low,  humid  or  imperfectly  ventilated  place,  the 
custom  of  wearing  tight  corsets,  and  of  reading  works  which  pro- 
duce turgescence  of  the  uterus.  Chronic  metritis  is  most  common 
from  the  twentieth  to  the  fortieth  year  ; it  occurs  more  particularly 
in  women  who  have  borne  several  children,  who  have  had  easy 
abortions  or  premature  confinements ; in  young  women  without  chil- 
dren, and  in  girls  at  puberty,  whose  menstruation  is  painful  and 
irregular,  and  finally  in  women  approaching  the  critital  age. 

When  this  disease  is  primary,  it  may,  like  acute  metritis,  be  deter- 
mined by  excessive  coitus,  by  masturbation,  by  the  presence  of  a 
pessary  in  the  vagina,  by  herpetic  or  rheumatic  metastasis ; by  the 
cooling  of  the  extremities  during  or  after  violent  exercise;  by  the 
application  of  a cold  body  to  the  thighs  to  suppress  uterine  hemor- 
rhage ; by  cosmetic  lotions  during  or  after  the  flow  of  the  menses ; 
by  sitting  on  a cool  and  damp  place,  as  a stone-seat,  or  the  grass  ; the 
immoderate  use  of  ices  or  sherbets  at  balls ; violent  emmenagogues, 
prolonged  celibacy,  and  absolute  continence  ; the  real  or  relative  dis- 
proportion of  the  sexual  organs  ; the  presence  of  one  or  more  polypi 
and  attempts  at  their  ligature  or  extraction ; the  forced  dilatation  of 
the  mouth  of  the  uterus ; the  use  of  foot-stoves  and  exposure  of  the 
genital  parts  to  great  heat ; the  use  of  tea  or  of  alcoholic  drinks  ; and 
finally,  this  affection  may  come  on  sometimes  without  appreciable 
cause  that  can  be  explained.  Chronic  metritis  is  generally  difficult 
to  recognize  at  the  commencement,  and  we  may  at  most,  perhaps, 
suspect  its  existence,  because  of  the  changes  which  occur  in  the 
temper  of  the  woman,  who  becomes  sad,  melancholy,  impatient  and 
irascible.  But  these  symptoms  are  commonly  useless  to  the  physi- 
cian, who  is  seldom  consulted  previous  to  a period  at  which  the  dis- 
ease is  made  evident  by  symptoms  sufficiently  distinct  to  remove 
all  uncertainty. 

In  order  to  place  the  diagnosis  and  treatment  of  subacute  and 
chronic  metritis  in  greater  order  or  clearness,  we  shall  mention  the 
principal  forms  under  which  it  presents  itself  to  observation,  to  wit : 
1.  Subacute  and  simple  inflammation  without  engorgement;  2. 
Chronic  inflammation  with  engorgement ; 3.  Subacute  and  chronic 
catarrhal  inflammation  ; 4.  Inflammation  with  ulceration ; 5.  In- 
flammation with  granulations. 

CHRONIC  METRITIS  WITHOUT  ENGORGEMENT. 

This  form  of  chronic  metritis  has  been  described  by  M.  Lisfranc,  and 
called  by  that  able  practitioner,  sub-inflammation  without  engorge- 
ment ; it  is  characterized  by  acute  pain  increased  by  long  standing, 
by  exercise  on  foot  and  in  a carriage,  and  especially  by  coitus. 
Women  attacked  by  it  feel  a sensation  of  great  heat  and  smarting  in 
the  pelvis,  accompanied  with  weight  in  the  lumbar  and  iliac  regions, 


CHRONIC  METRITIS. 


295 


and  a kind  of  turgescence  and  burning  heat  in  the  uterus.  The 
sensibility  of  the  organ  is  so  much  augmented,  that  the  effort  to 
expel  the  faecal  matter  gives  pain. 

Notwithstanding  these  symptoms  of  irritation,  in  whatever  mode 
the  Touch  is  performed,  we  find  nothing  anormai  in  the  volume,  con- 
sistence or  situation  of  the  neck  and  body  of  the  gestative  organ,  un- 
less it  be  that  the  orifice  of  the  uterus  presents  a rather  greater  degree 
of  dilatation  than  is  customary.  The  introduction  of  the  finger  and 
still  more  of  the  speculum  into  the  vagina  is  extremely  painful ; 
this  latter  mode  of  exploration  enables  us  to  ascertain  that  the  os 
tincae  is  free  from  engorgement,  and  presents  nothing  anormai. 

This  sort  of  chronic  metritis,  without  appreciable  change  in  the 
uterus,  sometimes  comes  on  without  any  evident  cause,  and  pro- 
duces pains  which  are  remittent  or  more  frequently  intermittent.  It 
is  chiefly  on  this  account  that  most  practitioners,  regarding  the  affec- 
tion as  purely  nervous,  are  satisfied  to  prescribe  palliative  means,  or 
they  abandon  the  disease 'to  itself,  whence  it  happens  that  it  makes 
rapid  progress,  and  the  pains  constantly  go  on  augmenting. 

It  is  therefore  of  the  greatest  importance  to  recur  from  the  first  to 
antiphlogistics,  and  especially  to  general  bleeding,  to  baths,  to  emol- 
lient and  narcotic  enemata,  to  demulcent  drinks,  etc.  If  the  pain 
continues  to  attack  in  paroxysms,  we  might  resort  to  the  use  of  sul- 
phate of  quinia,  combined  with  the  watery  extract  of  opium. 

CHRONIC  METRITIS  WITH  ENGORGEMENT. 

It  is  under  this  form  that  chronic  metritis  most  frequently  presents 
itself  to  our  observation. 

The  engorgements  of  which  the  neck  or  body  of  the  womb  may 
be  the  seat,  ought  to  be  divided  into  two  classes,  presenting  several 
varieties. 

In  the  first  class,  comprising  all  the  engorgements  without  indura- 
tion, are  found,  simple  hypertrophy,  oedematous  engorgement,  and 
sanguine  engorgement,  with  or  without  haemorrhage  ; in  the  second 
class,  which  comprises  *engorgement  with  induration,  we  range 
hypertrophy  with  induration  or  simple  white  engorgement,  scirrhous 
engorgement,  and  tubercular  induration. 

Before  describing  the  sensible  signs  which  distinguish  all  these 
varieties  of  engorgement,  we  shall  enumerate  the  symptoms  which 
are  common  to  the  greater  part  of  them,  and  which  depend  in  part 
on  the  augmentation  in  weight  and  volume  of  the  uterine  organ,  as 
well  as  partly  upon  the  disturbance  of  the  neighbouring  parts. 

Commonly,  when  the  organ  is  the  seat  of  any  engorgement  or 
hypertrophy  whatever,  it  almost  always  prolapses,  either  preserving 
its  natural  direction,  or  taking  one  more  or  less  considerably  inclined. 
The  pressure,  which  in  this  case  is  exerted  upon  the  rectum  and 
bladder,  often  gives  rise  to  obstinate  constipation,  to  pains  more 
or  less  acute  in  the  expulsion  of  the  faecal  matter  and  urine,  and 
almost  always  to  a sensation  of  weight,  and  painful  troublesome 


296 


CHR0XIC  METRITIS. 


dragging  about  the  sacrum,  in  the  groins  and  loins,  and  even  along 
the  whole  extent  of  one  of  the  sciatic  nerves. 

We  must  add  to  these  symptoms  a feeling  of  heat,  a deep-seated 
obscure  pain  in  the  hypogaster,  which  increases  at  intervals  while 
standing,  or  walking,  and  especially  during  coitus,  from  the  pressure 
of  the  penis  on  the  os  tincae.  This  increase  of  pain  is  associated 
With  a sense  of  pruritus  and  rawness  in  the  pelvic  cavity,  and 
most  commonly  with  a transient  or  continued  fever,  in  either  case 
slight,  and  perceived  particularly  during  the  period  of  menstruation ; 
finally,  the  phenomena  common  to  all  the  chronic  inflammations  of 
the  womb,  under  whatever  form  observed,  are  the  following:  the 
women  suffer  remarkable  modifications  of  their  menstruation ; if 
their  menses  appear  at  the  ordinary  epoch,  they  generally  last  a 
shorter  time,  and  the  blood  is  pale  and  almost  serous ; when,  on  the 
contrary,  they  fail  for  several  months,  a haemorrhage  almost  always 
occurs,  which  lasts  ten,  fifteen  and  even  twenty  days,  and  which 
produces  discoloration  of  the  face,  feebleness  and  emaciation.  Be- 
tween each  menstrual  epoch,  there  takes  place  from  the  vulva  a sero- 
mucous  or  sanguineous,  or  even  a fetid  discharge,  which  has  been 
described  as  the  principal  character  of  confirmed  cancer,  and  the 
colour  of  which,  its  consistence  and  quantity,  are  extremely  varia- 
ble. Hysterical  phenomena  almost  always  appear,  especially  in 
young  women ; some  suffer  from  mammary  pains,  and  other  ner- 
vous symptoms,  such  as  palpitation,  cramp  and  formication  in  the 
legs,  oppression,  and  general  restlessness ; the  stomach,  which  is  con- 
nected with  the  uterus  by  the  strongest  sympathy,  almost  always 
partakes  of  the  pathological  condition  of  the  organ  ; the  patients  lose 
their  appetite ; their  digestion  is  laborious  and  accompanied  with 
nausea,  eructation,  and  vomiting,  which  is  peculiar,  inasmuch  as  it 
generally  relieves  the  female,  so  that  when  the  stomach  has  rejected 
the  first  aliment  that  it  contained,  what  is  afterwards  taken  may 
frequently  be  retained. 

When  the  disease  is  left  to  itself,  the  vaginal  discharges  become 
more  abundant  from  day  to  day,  the  health  steadily  deteriorates, 
the  debility  increases,  a slow  fever  sets  in,  finally  the  whole  economy 
seems  to  participate  in  the  morbid  condition  of  the  uterus,  whose 
chronic  inflammation  is  often  the  prelude  to  a fatal  disorder ; in  some 
cases,  on  the  contrary,  the  woman  seems  to  enjoy  a moderate  degree 
of  health  for  a long  time,  and  to  preserve  her  embonpoint,  colour 
and  strength  pretty  well,  notwithstanding  the  progress  of  the  dis- 
ease. 

The  major  part  of  the  symptoms  we  have  just  enumerated,  and 
which  can  be  learned  only  from  the  report  of  the  patient,  always 
indicate  that  the  uterus  is  in  a pathological  condition ; but  taken 
separately,  they  are  of  little  value  in  making  a positive  diagnosis, 
since  they  give  as  good  reason  to  suspect  the  existence  of  a com- 
mencing degeneration,  of  a polypous  tumour,  a prolapsus,  or  any 
other  lesion  of  situation,  as  to  clearly  show  that  the  gestative  organ 
is  the  seat  of  a chronic  phlegmasia,  or  of  a simple  or  ulcerated  en- 
gorgement. 


ENGORGEMENT  OF  THE  WOMB  WITHOUT  INDURATION.  2 97 


To  remove  all  uncertainty  upon  this  point,  it  becomes  necessary  to 
resort  to  the  touch  and  to  the  application  of  the  speculum,  which  are 
the  more  valuable  as  means  of  making  a good  diagnosis,  inasmuch 
as  they  alone  yield  us  certain  signs  for  recognizing  and  perfectly 
distinguishing  all  the  chronic  affections  of  the  uterus. 

ENGORGEMENT  OF  THE  UTERUS  WITHOUT  INDURATION. 

Uterine  engorgement  without  induration,  is  nothing  else  than  the 
disorder  called  by  M.  Lisfranc,  morbid  hypertrophy , the  chief  cha- 
racter of  which  is  an  augmentation  in  size  of  the  uterus  without 
alteration  of  tissue. 

The  engorgement  without  induration,  may  occupy  the  whole  of 
the  uterus,  or  simply  its  neck,  but  commonly  this  latter  part  is  alone 
affected,  and  it  is  well  to  remark  that  when  the  morbid  hypertrophy 
attacks  a part  of  the  gestative  organ,  it  occupies  it  entirely,  and  not 
by  isolated  points,  as  happens  in  scirrhous  engorgement. 

Chronic  metritis  without  induration,  is  recognized  not  only  by  the 
symptoms  which  we  have  already  enumerated,  but  also  by  other 
more  certain  signs  afforded  by  the  Touch  and  by  the  speculum. 

On  carrying  the  index-finger  into  the  vagina,  we  find  that  the  walls 
of  this  canal,  as  well  as  the  neck  of  the  uterus,  are  the  seat  of  anor- 
mal  heat  and  much  greater  sensibility  than  in  scirrhous  hypertrophy. 
The  os  tineas  and  the  body  of  the  womb  present  nearly  the  consist- 
ence proper  to  them  in  a pregnancy  of  a month  or  six  weeks.  Were 
we  desirous,  says  the  celebrated  surgeon  of  La  Pitie,  to  give  a com- 
parative idea  of  the  sensation  felt  by  the  finger,  we  should  call  to 
recollection  that  which  is  produced  by  a lipoma  not  yet  degenerated, 
or  the  mamma  of  a young  girl  who  has  perished  by  a sudden  death, 
or,  finally,  that  of  a body  slightly  compressible  or  resisting,  elastic  or 
somewhat  spongy;  in  performing  the  Touch  per  rectum,  we  feel  the 
body  of  the  uterus  yield  under  pressure,  as  though  we  pressed  upon 
a cushion  full  of  wool  or  cotton  which  had  been  compressed. 

The  orifice  of  the  neck  is  generally  found  more  dilated  than  in  its 
normal  state,  and  the  end  of  the  index-finger  may  frequently  be  car- 
ried into  it,  but  in  this  case  we  do  not  feel  the  sensation  of  craque- 
ment,  which  exists  in  engorgement  with  induration.  If  we  explore 
the  parts  by  means  of  the  speculum,  the  neck,  partly  effaced  and 
tumefied,  as  in  pregnancy,  is  of  a more  or  less  deep  red  colour,  and 
sometimes  even  of  a brown  or  vinous  red,  but  the  colour  is  uniform 
throughout  its  whole  extent ; nevertheless,  in  certain  cases,  small 
isolated  spots  may  be  remarked  here  and  there,  which  give  a dotted 
aspect  to  the  surface  of  the  os  tincse. 

It  is  of  the  utmost  importance  not  to  confound  simple  engorgement 
of  the  uterus  with  another  much  more  serious  affection  which  differs 
essentially  from  it,  and  which  is  nothing  else  than  softening  of  the 
uterine  parenchyma.  Where  this  pathological  condition  is  present, 
the  tissue  of  the  gestative  organ  recedes  under  the  pressure  of  the 
finger  like  the  skin  of  a rotten  apple;  instead  of  meeting  an  elastic 
spongy  tissue,  one  giving  the  sensation  of  the  mamma  of  a young 


298 


ENGORGEMENT  OF  THE  WOMB  WITHOUT  INDURATION. 


girl,  or  of  a lipomatous  tumour,  we  find  a pultaceous  aetheromatous 
tissue,  whose  envelopes  seem  to  contain  matters  having  the  consist- 
ence of  a brownish  bouillie  or  semi-fluid  honey;  this  morbid  condi- 
tion, which  is  often  accompanied  by  superficial  ulceration,  constitutes 
what  most  authors  have  called  occult  cancer. 

As  this  last  pathological  lesion  offers  no  chance  of  safety  except 
by  the  removal  of  the  degenerated  portions,  it  becomes  very  import- 
ant not  to  confound  it  with  simple  morbid  engorgement,  which  is 
very  curable,  and  never  requires  any  operation.  To  the  differential 
signs  which  we  have  just  mentioned,  we  might  add  that,  hypertrophy 
without  induration  is  ordinarily  of  recent  date,  and  that  it  occupies 
the  neck,  and  frequently  the  whole  of  the  womb,  while  scirrhus  and 
cancer  date  from  a more  distant  period,  and  remain  a longer  time 
limited  to  a small  portion  of  the  uterine  organ. 

The  treatment  of  this  kind  of  chronic  metritis  offers  two  different 
indications,  according  as  the  engorgement  exists  with  or  without 
pain  ; in  the  first  place,  we  should  have  recourse  to  antiphlogistics, 
to  emollient  and  soothing  drinks,  to  injections  nearly  cold,  and  to 
sedative  enemata  of  the  same  temperature  ; to  small  bleedings  from 
the  arm,  which  ought  to  be  rather  revulsive  than  depletory,  and 
which  should  be  used,  as  far  as  possible,  six  or  eight  days  after  the 
flow  of  the  menstruae,  with  the  view  of  dissipating  the  weight,  the 
pain,  and  the  remains  of  the  congestion  commonly  present  after  each 
menstrual  evacuation. 

If  the  woman,  however,  were  strong,  and  of  a sanguine  and  ple- 
thoric temperament,  the  treatment  should  be  opened  by  a depletory 
bleeding  of  eight  or  twelve  ounces.  In  every  case  we  should  pre- 
scribe absolute  rest,  complete  abstinence  from  the  conjugal  approach, 
and  the  patient  should  be  submitted  to  a regimen,  which  might  be 
somewhat  modified  according  to  her  habits  and  temperament,  but  in 
general  it  should  consist  of  vegetables,  white  meats,  fish,  preparations 
of  milk,  cooked  fruits,  etc. 

If  the  engorgement  were  accompanied  by  but  little  pain,  and  if 
there  remained  merely  a sensation  of  weight  in  the  pelvic  cavity, 
we  should,  in  like  manner,  have  recourse  to  the  remedy  already  men- 
tioned ; but  in  this  case  it  would  be  well,  (in  order  to  hasten  the  reso- 
lution,) to  allow  of  a little  exercise,  and  to  recur  to  revulsives,  such  as 
dry  or  scarified  cups,  douches  about  the  pelvis,  small  moxas,  whether 
after  the  method  of  .Baron  Larrey,  or  by  means  of  an  iron  hammer 
dipped  in  boiling  water,  as  recommended  by  M.  Mayor  of  Lau- 
sanne. For  ordinary  drink,  we  might  prescribe  bitter  infusions,  and 
allow  a moderate  coitus,  which,  by  procuring  slight  excitation,  might 
contribute  to  dissipate  the  remains  of  the  disease  ; in  case  the  woman 
should  continue,  notwithstanding  the  methodical  employment  of 
these  measures,  to  experience  some  uneasiness  and  pain  in  the  pelvis, 
we  should  assure  ourselves  of  the  state  of  the  parts  with  the  aid  of 
the  speculum,  and  should  excoriations  be  discovered  upon  the  os 
tincae,  we  might  cause  their  disappearance  by  cauterization  with  the 
acid  nitrate  of  mercury. 

Though  this  treatment  be  simple,  it  ought,  in  order  to  succeed,  to  be 


(EDEMA  OF  THE  OS  UTERI. 


299 


followed  scrupulously  and  with  perseverance,  for  the  cure,  which 
commonly  requires  from  one  to  three  months, may,  in  some  cases,  be 
prolonged  much  beyond  this.  The  patient  and  physician  should  then 
arm  themselves  with  patience,  and  not  judge  of  the  progress  of  the  cure 
by  the  march  of  the  pains,  for,  as  M.  Lisfranc  has  remarked,  these 
sometimes  augment  in  proportion  as  the  engorgement  diminishes. 


OF  (EDEMA  OF  THE  NECK  OF  THE  UTERUS. 

This  increase  in  size  of  the  neck  of  the  uterus,  which  has  been 
described  by  M.  Duparcque,*  is  an  extremely  rare  disorder,  which 
seems  principally  to  attack  women  of  the  lymphatic  temperament, 
subject  to  catarrhal  affections,  and  especially  to  old  and  profuse  leu- 
corrhoea. 

The  determining  causes  of  oedema  of  the  neck  of  the  womb  are 
unknown,  yet  it  would  appear  that  it  may  be  the  result  of  the  sudden 
suppression  of  an  abundant  and  serious  uterine  catarrh,  especially  in 
persons  convalescing  and  still  labouring  under  general  atony ; accord- 
ing to  M.  Duparcque,  (loco  citato)  this  affection  may  also  be  the 
result  of  violence  applied  to  the  neck  of  the  uterus  during  labour ; 
but  in  such  case,  the  oedematous  engorgement,  which  persists  or  aug- 
ments up  to  the  appearance  of  milk-fever,  diminishes  or  disappears 
ordinarily  before  six  weeks  or  two  months. 

In  performing  the  vaginal  examination,  the  neck  of  the  womb, 
which  is  commonly  depressed,  is  found  to  be  the  seat  of  a tumour  in 
form  of  a circular  swelling,  presenting  at  its  centre  an  infundibular 
depression  which  terminates  in  a narrow  orifice.  Carried  up  to  a 
level  with  the  insertion  of  the  vagina,  or  introduced  into  the  vagina, 
the  finger  readily  ascertains  that  the  tumour  is  strangulated  above, 
and  lost  in  the  body  of  the  uterus,  whose  size  is  not  increased.  The 
kind  of  engorgement  which  is  felt  is  indolent,  almost  insensible  to 
the  touch,  and  much  lighter  and  more  elastic  than  the  others ; more- 
over, it  will  always  be  easy  to  distinguish  and  establish  a certain 
diagnosis  by  means  of  the  speculum,  which  will  allow  us  to  perceive 
a transparent  whitish  tumour,  retaining  the  impression  of  the  finger, 
and  forming  a ring-like  projection,  which  seems  to  be  strangulated  at 
its  point  of  junction  with  the  uterus. 

It  appears  that  the  local  treatment  of  this  oedematous  affection, 
which  has  been  little  observed,  ought  to  consist  in  the  employment  of 
punctures  made  in  the  circumference  of  the  os  tines  and  in  astringent 
injections.  The  general  treatment  should  vary  according  to  the  cir- 
cumstances and  causes  which  have  produced  and  keep  up  the 
disease.  However,  in  the  greater  part  of  the  cases,  we  should  pre- 
scribe the  use  of  diuretics,  and  aromatic  sudorifics  conjointly  with 
stimulating  and  dry  fumigations,  made  with  gum  benzoin  or  juniper 
berries.  We  think  that  it  would  also  be  advantageous  to  recur, 
under  some  circumstances,  to  the  employment  of  tonics,  and  princi- 
pally the  martial  preparations. 


* Traits  des  Alterations  organiques  de  la  Matrice,  p.  92. 


300 


HYPERiEMIA  OF  THE  WOMB. 


SANGUINE  ENGORGEMENT  OF  THE  UTERUS  WITH  AND  WITHOUT 

HAEMORRHAGE. 

The  congestive  engorgements  which,  as  well  as  the  preceding, 
have  been  described  by  M.  Duparcque,  present  two  varieties,  whose 
characters  we  are  about  to  lay  down,  from  the  able  practitioner 
whom  we  have  just  cited. 

The  first  kind,  or  engorgement  from  simple  congestion,  besides  its 
development  at  the  menstrual  epochs  and  after  labour,  may  be  pro- 
duced by  all  the  general  causes  of  metritis,  and  the  special  excitants 
capable  of  provoking  and  maintaining  a too  considerable  sanguine 
afflux  towards  the  gestative  organ  ; simple  sanguine  engorgement, 
which  is  variable  in  its  size,  may  be  carried  to  such  a degree,  that 
the  womb  sometimes  acquires,  in  a little  while,  a volume  equal  to 
that  which  it  presents  at  the  fourth  or  fifth  months  of  pregnancy. 
This  state  of  congestion  of  the  uterine  parenchyma,  which  somewhat 
increases  the  natural  consistence  of  the  parts,  and  which  determines 
no  other  pain  than  that  which  results  from  the  contractions  of  the 
organ,  ought  not  to  be  confounded,  with  the  engorgement  produced  by 
acute  inflammation  of  the  womb.  The  latter  affection  may  be  distin- 
guished from  it  by  different  symptoms  which  we  will  describe  pre- 
sently, and  especially  by  great  sensibility  ; by  the  less  considerable 
development  of  the  organ,  and  by  all  the  general  and  local  phe- 
nomena indicative  of  inflammatory  action. 

According  to  M.  Duparcque,  whom  we  quote  literally,  the  symp- 
toms of  sanguine  engorgement  of  the  uterus,  are  nearly  the  same 
as  those  of  metritis,  but  in  a less  degree ; sensation  of  enlargement, 
tension  and  weight  in  the  pelvis;  lumbar,  sacral  and  inguinal 
pains ; uterine  pains,  in  paroxysms  more  or  less  frequently  re- 
peated and  prolonged,  during  which,  it  seems  as  though  the  uterus 
contracted  violently  to  expel  the  blood  with  which  it  is  engorged ; 
peculiar  pains,  known  by  the  name  of  uterine  colic  or  cramp  ; ute- 
rine tenesmus ; and  lastly  tormina.  These  pains  are  sometimes  so 
violent,  that  the  patients  are  forced  to  bow  themselves  strongly 
while  they  last.  Nevertheless,  pressure,  as  well  as  the  touch,  show 
the  insensibility  of  the  engorged  parts,  at  least  in  the  intervals  of 
the  tormina,  which  is  the  reverse  of  engorgement  with  inflammation, 
a case  accompanied  by  most  violent  pains  and  constant  soreness. 

The  general  symptoms,  sometimes  absent,  at  other  times  very 
marked,  bear  upon  the  nervous  and  circulatory  system ; whence 
various  forms  of  neurosis,  and  also  fever,  a general  condition  rare 
at  this  time,  or  which  lasts  but  a short  time. 

M.  Duparcque  has  reported  several  cases  which  prove  that  en- 
gorgement from  congestion  passes  into  the  condition  of  subacute 
inflammation,  and  thence  into  the  most  profound  organic  transfor- 
mations. He  adds  that  this  affection  often  serves  as  a prodrome  to 
acute  and  chronic  metritis,  as  well  as  to  the  haemorrhagic  engorge- 
ments of  which  we  are  about  to  speak.  When  the  congestion  exists, 
the  slightest  causes  may  develop  inflammation  or  excite  sanguine 
losses.  Besides,  simple  and  recent  sanguine  engorgement  leaves  few 


HYPER2EMIA  OP  THE  WOMB. 


301 


or  no  traces  at  the  autopsy,  because,  at  death,  the  engorging  fluids 
retrograde  and  abandon  the  vascular  system  of  the  gestative  organ. 

The  treatment  of  this  affection  ought  to  consist,  first,  in  the  dimi- 
nution of  the  fluxionary  movement,  by  removing  the  causes  which 
have  determined  or  which  maintain  it,  and  in  recalling  it  towards  the 
other  organs  by  means  of  derivative  bleedings,  of  cups,  and  of  irri- 
tants applied  more  or  less  freely  to  the  congested  organ.  If,  after 
the  employment  of  derivatives,  the  engorgement  should  not  be  dissi- 
pated, we  must  encourage  the  establishment  of  the  local  haemorrhagic 
flux,  which  is  the  most  natural  mode  of  termination  of  the  uterine 
congestion.  Then,  we  must  resort  to  local  baths,  to  relaxing  drinks, 
to  emollient  applications,  to  antispasmodics,  and  to  sedatives,  to  com- 
bat, at  the  same  time,  the  rigidity  of  the  womb,  which,  as  well  as  the 
nervous  and  anormal  condition  of  this  organ,  may  be  the  cause  of  the 
retention  of  the  sanguine  flux.  Finally,  we  might  supply  the  place 
of  this  discharge  by  means  of  an  application  of  leeches  to  the  os 
tincge ; and  if  the  congestive  engorgement  be  kept  up  by  an  atonic 
state  of  the  organ,  it  should  be  treated  by  astringents  or  by  ergot,  to 
the  amount  of  a drachm,  taken  in  doses  consisting  of  several  grains, 
and  repeated  every  two  hours.  If  the  sanguine  congestion  should 
resist  means,  based  upon  the  principles  which  we  have  just  ex- 
plained, it  is  probable  that  we  have  to  do  with  some  other  altera- 
tion, which  we  should  seek  to  recognize  and  oppose  by  therapeutical 
agents,  to  vary  according  to  the  nature  of  the  disease. 

CONGESTIVE  ENGORGEMENT,  WITH  HEMORRHAGE. 

This  species  of  engorgement,  which  may  occupy  the  whole  or 
only  the  neck  of  the  uterus,  develops  itself  in  the  same  manner  as 
the  preceding  ; it  is  likewise  produced  by  the  same  causes,  that  is  to 
say,  by  a fluxionary  movement,  which,  in  this  case,  is  excessive,  and,  • 
in  particular,  more  prolonged;  and  which,  moreover,  is  always  accom- 
panied by  an  abundant  and  continual  haemorrhage.  This  sanguine 
discharge  from  the  vulva,  the  colour,  quantity  and  consistence  of 
which  are  variable,  is  the  most  constant  symptom  of  the  engorge- 
ment which  occupies  our  attention. 

If  we  explore  the  parts  by  means  both  of  the  Touch  and  specu- 
lum, we  find  the  neck  tumefied,  softened  and  of  a more  or  less  deep 
red  colour;  the  mouth  of  the  uterus,  which  is  enlarged  in  proportion  to 
the  engorgement,  as  well  as  the  whole  surface  of  the  tumour,  is  the 
seat  of  a sanguine  exudation  which,  though  often  considerable  and 
permanent,  does  not  at  all  diminish  the  congestion.  The  os  tincae, 
covered  with  clotted  blood,  appears  smooth  to  view,  but  somewhat 
uneven  to  the  touch ; by  gentle  pressure,  we  perceive  a slight  sen- 
sation of  crepitation,  and  cause  an  oozing  of  black  blood,  which 
escapes  as  from  a sponge. 

The  general  phenomena,  which  are  the  consequence  of  the  con- 
tinual losses  of  blood,  vary  according  to  their  duration  and  amount. 
The  skin  becomes  tense  and  pale,  the  strength  gradually  diminishes, 


302 


CONGESTIVE  ENGORGEMENT  WITH  HEMORRHAGE. 


and  the  patient,  who  feels  a sensation  of  dragging  and  weakness  in 
the  praecordial  and  hypogastric  regions,  soon  loses  her  appetite,  or 
it  sometimes  becomes  insatiable. 

When  the  disease  has  reached  its  last,  stage,  the  skin  assumes  a 
yellowish,  straw  tint,  as  in  ordinary  cancerous  affections  ; the  eyes 
seem  dull,  and  if  some  women  are  observed  to  retain  a certain 
degree  of  embonpoint,  it  is  because  the  surface  of  their  bodies  has 
become  the  seat  of  a general  bloating  which  conceals  the  wasting 
of  their  muscles.  On  examination  per  vaginam,  the  neck  of  the 
uterus  is  found  to  be  macerated,  and  transformed  into  a sort  of  ulcer, 
presenting  a layer,  which  is  softened  and  putrid,  surrounded  by  a 
hard,  and,  as  it  were,  scirrhous  tissue.  Haemorrhagic  engorgement, 
which  has  reached  this  stage,  is  extremely  serious,  and  there  is  no 
hope  of  seeing  tissues  so  profoundly  changed,  return  to  their  normal 
condition.  When  the  disorder  is  recent,  or  seems  to  be  the  continua- 
tion or  augmentation  of  the  haemorrhagic  congestion  of  the  menstrual 
epochs  or  of  labour,  the  prognosis  is  less  unfavourable,  and  we  may 
even  hope  to  obtain  a perfect  cure  by  resorting  to  a rational  plan  of 
treatment,  one  modified  according  to  circumstances.  In  general,  the 
danger  of  the  disease  is  in  proportion  to  the  violence  and  duration  of 
the  uterine  haemorrhages. 

The  treatment  of  engorgement  from  congestion  with  sanguine 
discharge,  in  the  early  stage,  that  is  to  say,  without  softening  of  the 
tissues,  is  nearly  the  same  as  that  of  engorgement  from  simple  con- 
gestion: thus,  it  should,  like  that,  be  at  first  confined  to  derivative 
bleedings,  to  dry  and  scarified  cups,  to  sinapisms,  etc.  If,  as  often 
happens,  these  remedies  should  not  arrest  the  fluxionary  movement, 
and  consequently  the  uterine  discharges,  the  employment  of  bleeding 
should  be  abandoned,  in  order  to  recur  to  an  astringent  and  styptic 
medication,  which,  though  injurious  in  the  commencement,  suits  very 
well  where  the  haemorrhagic  engorgement  is  maintained  by  an  atonic 
and  relaxed  condition  of  the  diseased  tissues,  which  is  mostly  the 
case  where  the  disease,  existing  for  a long  period,  has  occasioned  a 
general  debility.  In  this  condition,  we  may  obtain  the  happiest 
results,  from  the  internal  use  of  extract  of  rhatany,  of  decoctions  of 
oak- bark,  solutions  of  alum,  the  mineral  acids,  ferruginous  prepara- 
tions and  natural  or  artificial  ferruginous  mineral  waters ; amongst 
others,  those  of  Spa,  of  Forges,  of  Passy,  etc.;  finally,  ergot  seems, 
in  some  cases,  to  offer  advantages  which  have  been  ascertained  by 
several  practitioners,  particularly  by  Dr.  Duparcque.  When  the  dis- 
ease has  reached  such  an  extent  that  the  parts  have  become  softened 
and  disorganized,  the  medical  treatment  should  be  limited  to  the  use 
of  palliatives.  We  can  hope  to  effect  a cure  only  by  the  destruction 
of  the  diseased  part,  by  means  of  a cutting  instrument  or  by  cauteri- 
zation ; but,  unfortunately,  it  is  difficult,  and  even  impossible,  to  ascer- 
tain the  limits  of  the  alteration,  and  consequently  to  know  whether  it 
be  entirely  accessible  to  surgical  operations.  We  shall  conclude  by 
saying  that  engorgement  from  congestion,  with  haemorrhage,  presents 
so  great  an  analogy  to  fungous  haematodes,  that  it  is  probable  that  a 
large  number  of  the  cases  of  fungous  cancer  of  the  womb,  reported 


PRIMARY  ENGORGEMENT  WITH  INDURATION. 


30  3 


by  authors,  were  nothing  more  than  haemorrhagic  engorgement, 
in  the  last  stage.  What  especially  distinguishes  the  latter  lesion 
from  the  cases  of  fungus  is,  that  the  haemorrhages  accompanying  it 
are  more  obstinate,  more  abundant  and  more  constant,  and  that  the 
tumour  does  not  present  a narrowed  base  and  indurated  pedicle, 
as  usually  happens  in  fungous  cancers  of  the  uterus.  This  distinc- 
tion is  of  the  greatest  importance  for  the  surgical  treatment ; in  the 
fungus  we  may  hope  to  attain  the  limits  of  the  disease,  while,  in 
haemorrhagic  engorgement,  it  often  happens  that  the  alteration  of 
tissue  extends  as  far  as  the  body  of  the  organ,  which  contra-indicates 
any  surgical  operation,  which  is,  nevertheless,  the  only  means  to  be 
employed  with  any  hope  of  success. 

After  death,  we  find  the  cervix  uteri  swollen,  and  transformed 
into  a soft,  friable  tissue,  of  a blackish  colour  The  parenchyma  of 
the  uterus  is  also  more  or  less  disorganized,  and  reduced  into  a mass 
of  libro-cellular  and  vascular  filaments,  tearing  readily,  and  lost  in 
the  midst  of  black  and  coagulated  blood  with  which  it  has  been 
infiltrated ; M.  Duparcque  compares  this  alteration  to  the  tissue  of 
an  engorged  and  semi-putrified  spleen.  The  external  surface  of  the 
organ  commonly  presents  a layer  of  healthy  tissue  of  greater  or  less 
thickness,  whilst  the  parenchyma  is  found  the  more  disorganized, 
the  nearer  to  the  cavity  of  the  uterus  we  examine  it. 

OF  PRIMARY  ENGORGEMENT  WITH  INDURATION. 

This  kind  of  engorgement  with  induration  offers  more  than  one 
point  of  similarity  with  simple  engorgement  without  induration.  It 
is  produced  by  the  same  causes,  announced  by  the  same  symptoms, 
and  gives  rise  to  the  same  general  disorders ; but  the  hardening  of 
the  tissue  of  the  womb,  which  the  touch  reveals  to  us,  is  so  charac- 
teristic a sign  of  engorgement  with  induration,  that  it  is  impossible 
to  mistake  it  for  the  morbid  hypertrophy  without  induration,  of 
which  we  have  spoken  before. 

Simple  white  engorgement  with  induration  ordinarily  dates  from 
a period  not  long  foregone  and  the  greater  part  of  the  patients  say 
that  their  sufferings  have  begun  after  a sudden  suppression  of  their 
menstruas,  after  a recent  abortion,  or  a labour  which,  like  the  other 
two  accidents,  has  taken  place  within  two  or  three  months.  The 
recent  origin  of  the  induration  renders  the  cure  commonly  prompt 
and  easy,  but  it  is  important  to  distinguish  this  species  of  engorge- 
ment from  scirrhous  engorgement. 

In  both  cases,  the  pain  may  be  null  or  equally  lancinating,  and  in 
performing  the  Touch,  we  discover  that  the  womb  is  a weight 
and  volume  more  considerable  than  in  its  normal  condition.  In 
engorgement  with  simple  induration,  the  tissue  is  rather  less  hard, 
and  presents  an  even  surface  of  a rose  colour;  while  the  scirrhous 
engorgement  exhibits  bosses  and  irregularities,  and  besides  the  mu- 
cous membrane  of  the  cervix  uteri,  which  appears  of  a dull  white 
colour,  is  much  more  sensible  to  the  touch.  Finally,  the  treatment 
being  the  same  in  all  points,  hypertrophy  with  simple  induration, 


304 


SCIRRHOUS  ENGORGEMENT. 


generally  requires  a treatment  of  only  one  or  two  months ; it  requires, 
on  the  contrary,  a much  longer  time  to  obtain  the  resolution  of  a scir- 
rhous engorgement,  which  becomes  extremely  difficult,  and  even  im- 
possible where  the  disease  is  ancient.  M.  Duparcque  says  very  justly 
that  it  is  not  easy  to  seize  upon  the  transition  of  hard  engorgements 
from  the  curable  to  the  incurable  state ; it  is  in  fact  only  upon 
eventual  circumstances  that  we  can,  in  this  respect,  establish  a diag- 
nosis. According  to  this  author,  the  cure  is  possible  so  long  as  the 
induration  continues  to  be  formed  of  a fibro-albuminous  substance, 
disposed  in  the  meshes  of  the  cellular  tissue  of  the  diseased  organ ; 
but  the  resolution  cannot  take  place,  when  the  same  substance 
passes  into  the  cartilaginous  condition,  and  still  more  into  a state  of 
ossification.  Moreover,  the  diagnosis  is  less  important  than  one 
might  suppose,  because  the  treatment  is  the  same  in  either  case,  only 
the  chances  of  cure  are  very  different.  The  curative  means  of  the 
hard  primary  engorgements  are  equally  indicated  in  the  scirrhous 
engorgements;  but  then  they  are  merely  palliatives,  which  some- 
times arrest  the  progress  of  the  disease  and  render  the  pain  much 
more  bearable. 

The  treatment  of  simple  engorgement  with  induration  differs  but 
little  from  that  of  simple  engorgement  without  induration ; that  is  to 
say,  we  must  first  resort  to  antiphlogistics,  then  to  resolvents  and 
discutients,  administered  either  internally,  or  externally  in  the  form 
of  frictions.  Sulphurous  baths,  and  ascending  douches  about  the 
neck  and  the  pelvis  are  likewise  prescribed  with  advantage.  Finally, 
if  the  disease  prove  refractory,  we  may  add  to  these  means  the 
powerful  revellents,  such  as  moxas,  setons,  the  cautery,  etc.  Gene- 
rally speaking,  the  disease  readily  yields  to  the  remedies  directed 
against  it.  Sometimes  the  cure  is  effected  by  the  efforts  of  nature 
alone,  but  commonly,  when  the  disease  is  left  to  itself,  it  degene- 
rates into  scirrhus,  and  is  soon  beyond  the  resources  of  our  art. 


OF  SCIRRHOUS  ENGORGEMENT. 

Scirrhous  engorgement  is  produced  by  the  same  causes,  and  pre- 
sents the  same  symptoms  as  simple  engorgement  with  or  without 
induration:  although  the  lancinating  pain  which  it  determines  is 
commonly  more  acute,  and  more  frequent,  we  should  not,  as  most 
authors  pretend,  regard  it  as  having  an  essential  character,  since  it 
may  exist  in  engorgement  without  scirrhous  degeneration. 

The  symptoms  that  particularly  distinguish  scirrhus  of  the  neck 
of  the  womb  are,  as  we  have  already  said,  the  slowness  with  which 
the  tumour  is  developed,  the  hardness,  comparable  to  that  of  a petri- 
faction, and  the  irregularities  and  protuberances  which  the  finger 
meets  with  when  we  examine  per  vaginam;  finally,  the  dull  white 
colour  or  ivory  yellow  which  the  cervix  uteri  presents  when  the  parts 
are  examined  with  the  speculum. 

The  treatment  does  not  differ  from  that  of  engorgement  with  sim- 
ple induration  ; it  should  never  be  lost  sight  of  that  from  the  treatment 
being  generally  very  protracted,  it  becomes  necessary,  for  that  reason, 


SCIRRHOUS  ENGORGEMENT. 


305 


to  husband  the  strength  of  the  patient,  and  not  to  recur  to  sanguine 
evacuations  except  with  much  Care  and  prudence  ; besides,  we  must 
moderate  the  activity  of  the  circulation  by  the  use  of  cooling  drinks, 
baths,  repose,  rigorous  diet,  the  internal  use  of  nitre,  and  of  digitalis ; 
and  with  the  view  of  modifying  the  organic  elements  of  the  blood 
which  seem  more  especially  to  concur  in  the  formation  of  scirrhous 
engorgements,  we  should  insist  more  upon  pills  of  soap,  the  saline 
laxatives,  exutories,  diaphoretics,  etc.  Finally,  in  order  as  far  as  pos- 
sible to  direct  the  sanguine  affhixion  towards  parts  more  or  less  dis- 
tant, we  should  frequently  repeat  dry  cupping,  stimulating  frictions  of 
the  skin,  flying  sinapisms,  sulphurous  baths,  douches,  etc.  In  speak- 
ing of  the  general  treatment  of  engorgements  of  the  uterus,  we  shall 
treat  of  the  mode  of  employing  the  different  remedies  in  question, 
and  the  different  modifications  which  their  application  demands,  ac- 
cording to  circumstances. 

Though  most  authors  have  regarded  the  hard  engorgements  as 
nearly  incurable,  we  believe,  with  MM.  Lisfranc,  Recamier,  Du- 
parcque  and  other  distinguished  practitioners  of  our  period,  that 
scirrhous  tumours  of  the  womb  may,  as  often  happens  for  those  of 
the  breasts,  yield  to  a persevering  and  well-directed  treatment.  The 
three  practitioners  whom  we  have  cited  have  published  numerous 
cases  which  confirm  this  opinion;  besides,  if  Hippocrates,  Galen, 
Fearon,  Hufeland,  Ledran,  Vacher,  Pouteau,  Marc  Antoine  Petit, 
of  Lyons,  MM.  Recamier  and  Lisfranc,  and  some  others,  have  suc- 
ceeded in  dissipating  indurated  tumours  of  the  mammae,  wherefore 
refuse  to  admit  a similar  result  for  hard  and  chronic  engorgements 
of  the  uterus  ? What  proves,  moreover,  the  practicability  of  the  reso- 
lution of  scirrhous  tumours,  is  that  it  has  been  found  to  result  from 
the  efforts  of  nature  alone  ? M.  Pauly  reports  that  two  women,  con- 
demned by  M.  Lisfranc  as  having  an  engorgement  of  the  womb, 
recovered  perfectly  without  being  submitted  to  any  treatment.  {Ma- 
ladies de  V Uterus,  p.  315.) 

We  shall  conclude  by  saying  that  ail  hard  engorgements,  simple, 
or  presumed  of  scirrhous  nature,  which  have  been  developed  after 
some  disorder  of  the  menstruation  or  after  labour,  are  generally 
susceptible  of  resolution.  Those  that  commence  or  augment  at  the 
critical  age  commonly  resist  all  the  means  opposed  to  them;  but 
with  the  aid  of  a well-directed  treatment,  they  often  remain  station- 
ary. Finally,  the  hard  engagements,  whose  prognosis  is  most  un- 
favourable, are  those  which  are  covered  with  soft  protuberances,  and 
which  occasion  lancinating  and  deep-seated  pains;  in  such  a case, 
we  may  be  certain  of  their  early  and  inevitable  transformation  into 
ulcerated  cancer. 


TUBERCULAR  INDURATION. 

Tubercular  induration  of  the  uterus  is  more  frequent  than  is  gene- 
rally supposed.  It  mostly  attacks  women  of  lymphatic  temperament 
and  of  feeble  and  delicate  constitution.  The  nature  of  this  affection, 
and  the  immediate  cause  which  produces  it  are  unknown ; we,  how- 
20 


306 


SCIRRHOUS  ENGORGEMENT. 


ever,  range  ourselves  on  the  side  of  those  physicians  who  regard  it 
as  the  effect  of  a chronic  inflammation,  which  may  develop  itself 
only  in  persons  who  are  predisposed.  The  circumstances  which  it 
is  reasonable  to  allow  as  having  the  power  of  facilitating  the  pro- 
duction of  the  tubercular  induration  which  now  engages  us,  are  the 
internal  use  of  mercury,  want  of  exercise,  living  in  dark  rooms, 
sedentary  occupation,  a poor  diet,  and  several  other  causes,  which 
have  no  activity  without  a certain  predisposition  that  we  are  unable 
to  appreciate. 

The  signs  which  enable  us  to  recognize  tubercular  induration  of 
the  neck  of  the  womb  are  furnished  us  by  the  vaginal  Touch,  and  by 
exploration  with  the  speculum.  By  carrying  the  finger  to  the  os 
tincae  and  making  slight  pressure,  we  find  that  its  tissue  is  the  seat 
of  hard  points  which  form  a more  or  less  considerable  projection, 
and  which  are  separated  from  each  other  by  depressions  having  the 
normal  consistence  of  the  neck  of  the  womb  in  its  healthy  state.  It 
happens  sometimes,  however,  that  the  depressed  tissue  which  sepa- 
rates each  induration  is  found  to  be  hypertrophied  by  the  tubercular 
matter.  In  some  cases  the  salient  points  converted  gradually  and 
by  separate  portions  into  a puriform  fluid,  soon  open  and  give  rise  to 
little  scrofulous  ulcerations,  which  we  shall  speak  of  at  another 
time.  While  the  tubercles,  although  softened,  are  not  open,  they 
give  to  the  exploring  finger  the  sensation  of  a partial  degeneration, 
and  in  this  case  the  diagnosis  cannot  be  made  in  a very  positive  man- 
ner, because  we  then  rely  in  some  sort  only  upon  the  constitution 
of  the  female.  The  exploration  with  the  speculum  almost  always 
allows  of  our  discovering  the  nature  of  the  lesion,  when  the  tuber- 
cular engorgement  is  open,  because,  by  pressing  the  extremity  of  the 
instrument  gently  upon  the  cervix  uteri,  we  see  starting  from  the 
centre  of  the  opening  a drop  of  puriform  matter  of  a tubercular  nature. 

The  progress  of  this  disease  is  generally  slow;  it  commonly  threat- 
ens but  little  danger  in  itself,  since,  by  the  efforts  of  nature  alone,  tuber- 
cular cavities  have  been  seen  to  cicatrize  temporarily  or  definitively ; 
however,  this  fortunate  termination  ordinarily  takes  place  but  slowly, 
because  new  tubercular  cavities  often  form  in  proportion  as  the  old 
ones  advance  towards  cicatrization.  Moreover,  the  malady  demands 
the  local  and  general  treatment  proper  to  scrofulous  ulcerations;  that 
is  to  say,  in  cases  where  it  is  recent,  we  must  have  recourse  to  anti- 
phlogistics,  employed  with  care,  because  of  the  feeble  constitution  of 
the  patient ; we  should  then  prescribe,  especially  if  the  disease  be 
chronic,  the  bitter  infusions  of  hops  or  of  gentian,  the  ferruginous 
preparations,  the  tincture  of  iodine  in  doses  of  ten  to  thirty  drops 
daily,  the  use  of  sulphurous  waters,  particularly  those  of  Bonnes  and 
Barege,  natural  or  artificial,  mercurial  frictions  upon  the  internal  sur- 
face of  the  thighs  and  on  the  hypogastric  region  ; lastly,  resolvents, 
tonics,  and  all  the  therapeutic,  hygieinic  and  dietetic  means  which 
apply  to  tubercular  affections. 


LEUCORRHCEA  OR  WHITES. 


307 


OF  LEUCORRHCEA,  OR  THE  WHITES. 

Of  all  the  names  given  to  this  disease,  that  of  vterine  catarrh 
seems  at  first  the  most  correct,  because  it  is  agreed  that  we  shall 
comprise,  under  the  general  term  catarrh , all  inflammations  of  the 
mucous  membranes,  and  because  leucorrhcea  is  commonly  regarded 
as  being  the  result  of  an  inflammation  of  the  internal  membrane  of 
the  uterus.  Yet  if,  on  the  one  hand,  we  reflect  that  the  denomina- 
tion of  uterine  catarrh  does  not  separate  the  idea  of  leucorrhcea,  pro- 
perly so  called,  from  that  of  syphilitic  blennorrhagia,  which  it  is  always 
necessary  to  distinguish,  and  especially  in  practice  ; and,  on  the  other 
hand,  we  recollect  that  the  leucorrhoeal  discharge,  far  from  being 
always  the  result  of  inflammation  of  the  uterine  mucous  membrane, 
is  more  frequently  determined  by  relaxation  and  atony  of  the  utero- 
vaginal mucous  membrane,  it  will  be  conceded  that  the  term  uterine 
catarrh  is  not  beyond  the  reach  of  a just  criticism.  For  example, 
it  is  allowable  to  regard  as  the  result  of  an  inflammation  of  the  in- 
ternal membrane  of  the  womb,  that  leucorrhcea  which  succeeds  to 
warm  baths,  to  a debilitating  regimen,  and  especially  that  which, 
after  some  vivid  emotion,  appears  suddenly,  flows  without  pruritus, 
without  pain,  and  is  unaccompanied,  except  with  certain  nervous 
symptoms,  such  as  yawning,  slight  uneasiness  in  the  stomach,  and 
general  malaise  ceasing  with  the  moral  cause  which  gave  them  birth. 
Does  not  this  transient  state  bear  with  it  the  marks  rather  of  a debi- 
lity or  of  a spasmodic  affection  than  those  of  a true  inflammation  ? 
Can  we  more  properly  ascribe  to  a periodical  inflammatory  state,  the 
sero-mucous  flux  which  prepares,  completes,  or  even  substitutes  itself 
for  the  flow  of  the  menstruae  ? 

Although  the  word  leucorrhcea  does  not  in  itself  possess  perfect 
exactitude,  and  though  it  expresses  only  the  constant  symptom  of  a 
utero-vaginal  affection,  characterized  by  a discharge  more  or  less 
white,  we  have  thought  it  would  be  preferable  to  the  word  uterine 
catarrh,  whether,  because,  like  the  last,  it  does  not  make  us  infer  any 
thing  as  to  the  causes,  nature  and  seat  of  the  disease,  or  because  it  is, 
moreover,  consecrated  by  general  use. 

Leucorrhoea,  which  derives  its  name  from  two  Greek  words, 
white,  pfW,  I flow,  has  been  observed  from  the  highest  antiquity, 
and  has  received  almost  as  many  denominations  as  there  are  authors 
who  have  written  upon  it.  Hippocrates,  Aretasus,  Galen,  and  Avi- 
cenna treat  of  it  with  much  detail,  but,  like  most  of  their  successors, 
being  supported  only  by  the  anatomical  and  physiological  knowledge 
of  their  day,  they  have  emitted  opinions  more  or  less  incorrect  upon 
the  nature  and  seat  of  the  disease.  If  Avicenna  and  F.  Hoffman 
have  wandered  least  from  the  truth  in  assigning  the  vessels  secreting 
the  menstruae  as  the  point  of  departure  of  leucorrhcea,  Degraaf,  Heur- 
nius,  Severin  Pinault,  and  especially  Chareton,  Morgagni  and  Bon- 
net approach  much  more  nearly  to  it,  in  considering  this  discharge 
as  a pathological  secretion  of  the  mucous  glands,  whose  existence 
and  orifices  they  had  discovered  upon  the  interior  of  the  genital 
parts.  But  it  was  reserved  for  the  labours  of  modern  physicians, 


308 


LET7CORRHCEA  OR  WHITES. 


especially  those  of  Pinel  and  Bichat  to  describe  in  a positive  manner 
the  diseases,  organization  and  functions  of  the  mucous  membranes. 

Without  regarding  inflammation  as  the  sole  cause  of  leucorrhoea, 
we  assert,  that  whatever  be  the  origin  of  the  affection,  it  has,  as  a 
principal  and  constant  character,  an  anormal  secretion  of  mucous 
fluid,  more  or  less  white,  escaping  from  the  vulva  in  uncertain 
quantity,  and  of  variable  shades  and  consistence. 

Wishing  to  isolate  this  disease,  as  it  ought  to  be,  as  to  its  study  and 
treatment,  we  shall  comprehend,  under  the  name  leucorrhoea,  only 
the  essential  and  sero-mucous  supersecretion,  which  results  either 
from  simple  subacute  or  chronic  inflammation  of  the  utero-vaginal 
lining  membrane,  or  from  a state  of  general  or  local  atony.  We 
shall  not  treat  in  this  chapter,  therefore,  of  those  symptomatic  puru- 
lent discharges  which  depend  on  blennorrhagia  and  other  syphilitic 
affections,  of  acute  uterine  catarrh,  properly  so  called,  which  has  a 
rapid  course,  or  finally,  of  those  produced  by  the  presence  of  a pes- 
sary or  other  foreign  bodies,  by  various  alterations  of  the  uterus  and 
vagina,  as  by  scirrhous  polypous-fibrous  or  cancerous  tumours,  by 
ulcerations  of  the  os  tineas,  dropsy  and  suppuration  of  the  ovaries 
and  Fallopian  tubes,  and  various  other  lesions  which  it  is  useless  to 
recapitulate. 

Though  it  is  generally  agreed  at  present,  that  leucorrhoea  has  its 
immediate  source  in  the  follicles,  and  upon  the  whole  surface  of 
the  lining  membrane  of  the  uterus  and  vagina,  various  circumstances 
would  make  it  appear  probable  that  the  leucorrhoeal  discharge  may 
also  be  in  part  formed  by  a serous  exhalation  from  the  vessels  that 
secrete  the  menstrual  blood.  In  fact,  has  it  not  been  remarked, 
that  a serous  fluid,  regarded  as  slight  fluor  albus,  ordinarily  precedes 
the  eruption  of  the  menstruse,  and  that  when  this  latter  evacuation 
is  irregular,  it  alternates  with  a leucorrhoea  that  augments  in  pro- 
portion as  the  sanguine  discharge  is  less  abundant,  and  vice-versa. 
Do  we  not  also  see  suppression  of  the  menses  often  replaced  by  a 
salutary  leucorrhoea,  and  do  we  not  know,  as  Freind  has  observed, 
that  women,  who,  in  this  condition,  have  abundant  fluor  albus,  suffer 
less  injurious  results  from  their  suppression,  and  that'  the  same  phe- 
nomenon often  presents  itself  in  them  at  the  final  cessation  of  the 
menstruae.  Though  the  intimate  connections  of  these  two  evacuations 
can  be  rendered  still  more  evident  by  the  remark,  that  the  appearance 
of  the  menstrual  discharge  commonly  suspends  leucorrhoea,  it  may 
be  proved,  on  the  other  hand,  that  fluor  albus,  coming  on  during 
pregnancy,  is  furnished  solely  by  the  mucous  crypts  of  the  vagina, 
which,  moreover,  would  tend  to  prove  that  leucorrhoea  may  have  its 
origin  in  any  of  the  sources  that  we  have  just  mentioned,  or  in  either 
one  of  them  at  one  time.  Unfortunately,  positive  facts  are  wanting, 
and  without  them  there  remain  only  conjectures  and  uncertainty. 

In  populous  cities,  as  in  a most  favourable  soil,  leucorrhoea  is  deve- 
loped under  the  influence  of  so  great  a number  of  causes,  that  there 
are  few  women,  especially  at  Paris,  who  are  completely  exempt 
from  it.  Although  this  affection  makes  its  appearance,  particularly 
from  the  first  approach  of  menstruation  up  to  the  period  of  its  ces- 


LEUCORRHCEA  OR  WHITES. 


309 


sation,  there  is  no  age  free  from  it.  G.  P.  Neuter,  Johannes  Doleeus, 
Roderic  a Castro,  Fernel,  Morgagni,  met  with  little  girls  of  six  or 
eight  years  of  age  who  were  attacked  with  it ; we,  ourselves,  have 
had  occasion  to  observe  several  examples  of  it ; among  others  one  in 
a new-born  infant. 

Utero-vaginal  catarrh,  which  M.  Alibert  regards  justly  as  that  to 
which  the  female  is  most  frequently  subjected  by  her  peculiar  organic 
constitution,  may  likewise  be  allied  to  any  of  the  temperaments;  but 
a lymphatic  temperament,  general  debility,  a cachectic  state,  and  a 
certain  inflammatory  susceptibility  of  the  mucous  membranes,  pecu- 
liar to  certain  subjects,  are  circumstances  which  predispose  to  this 
affection. 

Thus  it  is  met  with  more  particularly  in  females  who  are  large, 
fair,  nervous,  hysterical,  slight,  delicate,  and  in  those  with  red  hair, 
and  who  have  the  skin  covered  with  stains.  Though  women  with  a 
brown  skin,  and  black  hair,  are  not  exempt  from  it,  it  belongs  rather 
to  those  who  are  in  the  opposite  circumstances. 

A temperature  habitually  cold  and  humid,  and  a prolonged  resi- 
dence in  low  marshy  regions,  also,  in  an  especial  manner  encourage 
the  production  of  leucorrhoea  ; it  is  chiefly  to  the  union  of  these  two 
conditions,  that  Sylvius  attributed  the  frequency  of  the  disease 
amongst  the  women  of  Holland,  which,  for  the  same  reason,  is  com- 
mon in  a part  of  Belgium,  in  Lower  Normandy,  and  in  certain  parts 
of  England. 

The  mode  of  life  to  which  the  social  condition  condemns  women 
inhabiting  large  cities,  delivers  them  over,  so  to  speak,  defenceless, 
against  the  numerous  causes  of  the  chronic  inflammations  of  the 
utero-vaginal  mucous  membrane. 

Thus,  in  populous  cities,  idleness,  effeminacy,  a sedentary  life,  the 
constant  contact  of  the  two  sexes,  and  the  frequenting  of  places 
where  every  thing  inspires  pleasure  ; prolonged  watching,  dancing, 
frivolous  occupations  and  the  study  of  the  arts  that  give  new  acti- 
vity to  the  imagination  ; erotic  reading,  the  pernicious  establishment 
of  an  early  and  artificial  puberty ; the  premature  shock  of  the 
genital  organs ; solitary  pleasures ; the  concentration  of  the  senti- 
ments and  thoughts  on  objects  which  keep  the  genital  organs  in  a 
sort  of  permanent  turgescence  and  excitation  : finally,  a number  of 
vicious  habits  and  excesses  of  all  kinds,  which,  by  introducing  modi- 
fications more  or  less  profound  into  the  general  constitution,  react 
more  particularly  upon  the  sensibility  of  the  womb,  which,  in  the 
female,  is  not  only  the  organ  most  apt  to  lend  itself  to  fluxionary 
movements,  but  likewise  the  centre  towards  which  all  the  morbific 
actions  seem  principally  to  tend. 

The  use  of  foot-stoves,  and  of  coffee  and  of  tea,  may  also  contribute 
a good  dSal  to  the  production  of  leucorrhoea;  the  same  is  true  of 
the  too  frequent  use  of  salt  meat  and  fish,  shell-fish,  farinaceous  sub- 
stances, whether  indigestible  or  too  succulent,  beer,  spiced  dishes, 
ablutions  too  often  repeated,  the  abuse  of  warm  baths,  of  purgatives, 
of  emmenagogues,  and  of  preparations  of  milk.  Nota  mild  sunt 
exempla , says  Stahl, puellas  mterdum  satis  dill  a jluxu  albo  curato 


310 


LEUCORRHCEA  OR  WHITES. 


■mansisse  immunes  ; ut  primum  vero  lac  sump  sere,  continuo  reci- 
divun  fuisse  passas. 

It  is  necessary  also  to  range  among  the  causes  of  leucorrhoea,  the 
sudden  cessation  of  excretions,  whether  natural  or  artificial,  amongst 
others  those  of  general  or  partial  perspiration  of  the  feet,  of  the  hands, 
and  of  the  arm-pits  ; there  are  some  women  in  whom  it  is  sufficient  to 
have  the  arms  uncovered,  to  wet  their  feet,  or  to  sit  down  upon  a 
cold  or  damp  body,  in  order  to  be  seized,  immediately,  almost,  with 
fluor  albus.  The  suppression  of  an  exutory,  such  as  a cautery,  a 
blister  or  a seton  ; that  of  an  habitual  vomiting,  of  a diarrhoea,  of  a 
hsemorrhoidal  discharge,  of  the  suppuration  of  an  old  ulcer;  the 
retrocession  of  cutaneous  eruptions,  of  an  herpetic,  psoric,  arthritic 
affection,  etc. ; lastly,  derangements  of  menstruation,  failure  of  lacta- 
tion, debility  of  the  gastric  system,  the  sudden  disappearance  of  a 
coryza,  of  a pulmonary  catarrh,  or  of  any  other  disease  of  the  mucous 
membrane ; these  are  all  likewise  so  many  causes  that  may  determine 
an  attack  of  leucorrhoea. 

The  close  sympathy  between  the  brain  and  the  organs  of  genera- 
tion, accounts,  to  a certain  degree,  for  the  development  or  augment- 
ation of  the  affection  which  engages  our  thoughts,  in  consequence  of 
a moral  disorder.  However  it  may  be,  we  often  see  it  suddenly  arise, 
or  become  increased,  when  it  already  exists,  under  the  influence  of 
some  vivid  emotion,  some  tormenting  chagrin,  some  profound  dis- 
appointment, anger,  or  sudden  fright,  etc.  A lady,  seeing  an  only 
daughter  on  the  point  of  being  torn  from  her  by  a cerebral  fever, 
was  suddenly  inundated  with  a leucorrhoeal  discharge.  A young 
girl,  twenty-three  years  old,  who  was  at  No.  12  of  the  Rue  Transo- 
nain,  during  the  night  of  the  13th  to  the  14th  of  April,  1834,  having 
seen  her  lover  killed  by  some  soldiers,  and  owing  her  own  safety  to 
chance  merely,  was  immediately  attacked  with  abundant  fluor  albus. 

Finally,  we  shall  conclude  what  we  have  to  say  upon  the  causes  of 
the  disorder,  by  adding  that  it  has  been  known  to  prevail  epidemi- 
cally, under  the  influence  of  inappreciable  and  fugitive  principles  of 
the  atmospheric  constitution,  often  noticed  under  entirely  opposite 
conditions. 

Morgagni,  Raulin  and  Broussonnet  have  had  occasion  to  observe 
epidemics  of  this  nature.  The  last  of  which  Raulin  was  witness, 
occurred  at  Paris,  in  1765,  during  a burning  heat  of  the  weather, 
and  excessive  drought.  Epidemic  leucorrhoea  has  also  been  observed 
during  cold  and  damp  weather.  Moreover,  the  latter  cause  of  the 
disease  is  one  of  the  most  frequent.  Weikard,  the  translator  of 
Brown,  states  that,  in  a convent  at  St.  Petersburg,  all  the  pupils  were 
affected  with  fluor  albus,  because  they  had  been  reared  in  exposure 
to  rigorous  cold,  under  the  pretext  of  giving  them  a more  robust 
constitution. 

As  acute  inflammation  of  the  utero-vaginal  mucous  membrane 
really  exists  only  in  recent  blennorrhagic  discharges,  or  in  those 
which  depend  upon  a local  cause ; for  example,  the  presence  of  a 
pessary,  or  of  some  other  foreign  body  in  the  genital  cavities;  upon 
the  constant  abuse  of  venery;  upon  criminal  copulation;  relative  or 


LEUCORRHCEA  OR  WHITES. 


311 


absolute  disproportion  of  the  organs;  masturbation,  irritating  in- 
jections, etc. : we  have  thought  it  right  not  to  speak,  in  this  place,  of 
acute  uterine  catarrh,  depending  on  the  causes  which  we  have  just 
mentioned,  in  order  not  to  present  to  the  consideration  of  the  reader, 
the  essential  leucorrhcea,  properly  so  called,  except  in  its  subacute 
and  chronic  forms,  which  are  the  true  types  of  the  disease.  This 
division,  which,  moreover,  has  no  inconvenience  in  practice,  has  the 
advantage  of  facilitating  the  study  of  the  disease,  and  especially  of 
distinguishing  it  from  the  symptomatic  discharges  and  acute  inflam- 
mations of  the  utero-vaginal  mucous  membrane,  with  which  it  is 
always  confounded. 

The  subacute  leucorrhcea  which  opens  with  truly  inflammatory 
symptoms,  and  sometimes  even  with  a febrile  movement,  begins  with 
slight  pruritus,  which  is  at  first  confined  to  the  vulva,  but  soon  extends 
itself  to  the  vagina  and  uterus.  The  patient  feels  dull  pain  in  the 
hypogaster,  sensation  of  heat  vand  weight  in  th'e  centre  of  the  pelvic 
cavity,  draggings  in  the  loins,  groins  and  thighs.  She  is  tormented 
by  frequent  desire  to  urinate,  and  sometimes  by  venereal  desires. 
The  voiding  of  the  urine  is  often  accompanied  with  some  difficulty, 
and  a feeling  of  uneasy  and  painful  heat.  Finally,  there  is  not  un- 
frequently  conjoined  with  these  different  phenomena  a sensation  of 
hysteric  strangulation  and  spasmodic  oppression  at  the  upper  part  of 
the  thorax. 

The  discharge,  which  is  at  first  small  in  quantity,  clear,  serous  or 
sanguineous,  especially  if  it  follows  uterine  haemorrhage,  soon  aug- 
ments, becomes  thicker,  and  presents  a colour  which  is  variable,  and 
which  may  be  white,  lactescent,  yellow  or  greenish.  The  secretion 
is  sometimes  so  abundant  that  the  female  is  compelled  to  guard 
herself,  as  during  the  menstrual  evacuation;  the  spots  on  her  linen 
are  yellow  or  greenish,  and  give  it  a starched  stiffness.  Exploration, 
by  means  of  the  touch  or  speculum,  reveals  to  us  that  all  the  genital 
parts  are  redder,  more  inflamed  and  more  sensitive ; that  the  neck 
of  the  womb  is  more  dilated  than  in  its  normal  state  ; finally,  that  the 
mucous  membrane  of  the  os  tincae  and  vagina  is  swollen,  doughy  and 
sometimes  even  excoriated  or  slightly  ulcerated. 

In  cases  of  recrudescent  leucorrhoea,  that  is  to  say,  those  which 
diminish,  augment,  or  disappear  alternately,  it  is  often  difficult  to 
distinguish  certainly  what  form  we  have  to  deal  with ; and  it  is  only 
by  groping,  that  we  are  able,  in  certain  equivocal  cases,  to  recognize 
the  true  character  of  the  affection,  and  direct  the  treatment  which 
suits  it.  We  should,  however,  regard  as  subacute  or  active,  the  leu- 
corrhma  that  alternates  with  the  menstruae,  at  least  during  the  day 
preceding  or  immediately  following  their  evacuation;  that  which 
comes  on  after  a universal  febrile  movement  in  young  and  sanguine 
women ; finally,  that  which  is  determined  by  the  constant  abuse  of 
coitus,  by  extreme  fatigue,  or  other  causes  of  general  excitation ; 
such,  for  example,  as  long  watching,  the  immoderate  use  of  sea- 
soned, salted  and  stimulating  dishes,  and  alcoholic  liquors,  etc. 

The  passive  chronic  leucorrhoea , although  succeeding  often  to  the 
subacute  form,  may  not  only  exist  without  presenting  any  inflam- 
matory character,  but  may  even  depend  primarily  upon  a state  of 


312 


LEUCORRHCEA  OR  WHITES. 


general  relaxation  or  local  debility.  The  chronic  lencorrhoeal  dis- 
charge resulting  from  this  form  is  met  with  chiefly  in  lymphatic 
women  and  those  of  a loose  fibre ; and  it  is  for  this  reason  that  the 
infirmity  is  much  more  common  in  cold  and  humid  regions.  It  is 
equally  frequent  in  women  whose  genital  organs  are  relaxed  by 
numerous  labours  or  excessive  venery.  It  co-exists  ordinarily  with 
chlorosis,  amenorrhoea,  and  may  be  the  cause,  the  effect,  or  index  of 
a state  of  general  atony  and  relaxation. 

Women  afflicted  with  chronic  leucorrhoea,  depending  on  debility 
of  the  genital  organs  or  of  the  general  constitution,  although  possess- 
ing a vermilion  tint  and  seeming  to  enjoy  good  health,  generally  have 
a peculiar  facies , which  may  help  to  enlighten  the  physician  and  lead 
to  the  recognition  of  the  disease ; the  face  and  lips  are  pale,  the  eyes 
surrounded  by  a dark  areola,  the  eyelids  are  often  swollen,  and, 
finally,  an  expression  of  languor  in  all  the  features  gives  to  their 
whole  appearance  an  air  of  dejection.  Quando  autem  de  matrice 
humor es  multi  sunt , oculi  dolent , caput  calidum  hahent  vel  lan - 
guidum  et  vertiginem  pa  Hunt  ur,  says  Hippocrates. 

Essential  chronic  leucorrhcea  is  never  accompanied  by  signs  of 
irritation  of  the  genital  organs ; the  period  of  its  invasion  is  almost 
always  unknown,  no  matter  what  the  cause  which  may  have  pro- 
duced it;  its  progress  is  very  irregular,  and  its  duration  unlimited. 
As  happens  in  the  acute  form,  the  colour,  consistence  and  quantity 
of  the  discharge  vary  in  different  cases ; its  amount  is  often  very 
slight,  and  it  is  then  a mere  inconvenience,  which  attention  to  clean- 
liness prevents  from  becoming  too  disagreeable;  at  other  times  it 
escapes  from  the  vulva  in  sufficient,  quantity  to  keep  the  external 
genital  organs  and  the  upper  part  of  the  thighs  constantly  wet,  and 
to  produce  slight  excoriations  and  superficial  inflammations  of  these 
parts,  which  are  easily  prevented  or  dispelled  by  lotions  and  topical 
bathing. 

It  happens,  not  unfrequently,  that  the  affection  is  complicated  with 
relaxation  of  the  vagina  and  falling  or  vicious  inclination  of  the 
uterus ; but  these  lesions  of  situation,  which  augment  the  inconve- 
niences of  leucorrhoea,  and  which  are  betrayed  by  sensations  of 
weight  about  the  rectum  and  bladder,  are  rather  the  effects  than  the 
causes  of  fluor  albus  properly  so  called. 

When  small  in  quantity,  the  discharge  is  commonly  mucous,  and 
hardly  stains  the  linen  ; it  has  scarcely  any  odour,  and  the  colour  is 
whitish  like  that  of  thick  whey.  If,  on  the  contrary,  the  leucorrhoga 
be  abundant,  the  mucous  discharge  is  usually  lactescent,  and  from  its 
colour  and  consistence  sometimes  bears  sufficient  resemblance  to 
milk  to  have  attracted  credence  to  the  so-called  milk  diseases  and 
to  give  plausibility  to  the  false  theories  of  the  humoralists.  Under 
these  circumstances  the  discharge,  when  dried,  stiffens  the  linen  and 
leaves  a grayish  spot,  deepest  at  its  edges,  very  similar  to  that 
produced  by  the  nasal  mucus.  Sometimes  the  secretion  is  more  con- 
sistent, fiocculent  and  even  caseiform ; when  abundant,  and  espe- 
cially when  of  long  standing,  whatever  be  its  colour  and  consistence, 
it  always  occasions  certain  lesions  of  the  functions,  and  a great  num- 
ber of  sympathetic  phenomena.  The  women  complain  of  weight  in 


LEUCORRHCEA  or  whites. 


313 


the  lumbar  and  hypogastric  regions,  of  vague  sensations  of  lassitude, 
of  pains  in  the  epigastrium  and  of  cholic.  They  suffer  from  depraved 
appetite,  from  acidity,  nauseous  eructation,  headache,  frequent  yawn- 
ing and  hiccough;  the  skin  is  cool,  and  sensitive, to  the  least  atmo- 
spheric Variation;  they  perspire  but  little;  they  complain  of  unusual 
heat  in  the  head,  of  vertigo,  syncope,  palpitation  of  the  heart,  exces- 
sive coldness  of  the  feet,  occasional  pains  under  the  left  breast ; the 
face  becomes  pale,  the  eyes  hollow,  and  they  weep  without  cause ; 
they  become  careless,  impatient,  and  feel  a sort  of  languor  and 
dejection,  a sensation  of  strangling  or  choking,  and  an  involuntary 
sadness ; they  are  apathetic,  melancholy,  hypochondriacal ; in  fine, 
they  never  exhibit  the  happy  physiognomy  characteristic  of  the  sex, 
and  are  often  tormented  by  erotic  desires,  which  drive  them  into 
vicious  habits,  and  at  the  same  time  augment  their  languor  and  ex- 
haustion. When  menstruation  becomes  re-established  in  cases  of 
amenorrhpea  and  chlorosis,  the  leucorrhceal  discharge  diminishes,  or 
ceases  entirely ; with  it  disappear  all  the  nervous  symptoms ; the 
paleness  soon  passes  away,  gaiety  returns,  and  the  functions  of  the 
stomach,  as  well  as  the  general  health,  return  to  their  natural  con- 
dition. 

When  the  discharge  is  constant,  profuse  and  of  long  standing,  ex- 
haustion and  degradation  of  the  constitution  are  soon  found  to  be  the 
unfortunate  and  necessary  results  of  this  dux,  which  never  ceases, 
and  which  seems  to  attract  to  itself  the  sources  of  all  the  other  excre- 
tions, and  thus  to  cause  a drain  upon  the  whole  economy.  The  skin 
now  becomes  more  and  more  discoloured,  the  emaciation  increases, 
the  flesh  becomes  loose,  the  breasts  are  soft,  the  pulse  small  and  fre- 
quent, and  the  breath  fetid ; the  eyelids  become  bloated,  the  legs  are 
always  cold,  and  the  whole  body  sometimes  becomes  oedematous. 
The  patient  complains  of  almost  continual  cholic,  and  of  pains  along 
the  vertebral  column,  in  the  loins,  hips  and  hypogastric  region.  She 
is  tormented  with  constant  thirst ; the  appetite  is  lost ; she  suffers 
from  habitual  pain  in  the  stomach  and  from  obstinate  constipa 
tion ; she  is  subject  to  nausea,  eructations  and  acid  vomiting ; the 
urine  is  turbid,  flocculent  and  in  small  quantity.  When  leucorrhoea 
reaches  this  degree  of  severity,  the  patient  acquires  a disgust  and 
indifference  for  every  thing ; her  faculties  become  enfeebled ; she  is 
unfitted  for  reproduction  as  much  by  her  indifference  as  by  the  dis- 
gust which  she  inspires : finally,  moral  debility  and  settled  despair, 
together  with  hectic  fever,  exhaust  the  few  remains  of  strength,  after 
having  destroyed  all  that  lends  a charm  to  life. 

Amongst  the  discharges  which  might  be  confounded  with  essential 
leucorrhoea,  are  naturally  found  those  which  depend  upon  a syphilitic 
taint,  and  those  which  are  symptomatic  of  some  other  more  or  less 
serious  affection  of  the  uterus  or  vagina;  Walter  Charleton,  Van 
Swieten,  De  Graff'  and  some  others  supposed  leucorrhoea  to  be  seated 
in  the  vagina  and  uterus,  whilst  blennorrhagic  discharges  have  their 
point  of  departure  at  the  entrance  of  the  vagina,  and  especially  in 
the  neighbourhood  of  the  urinary  meatus  and  in  the  lacunae  situated 
between  the  nymphae.  Astruc,  Baillou,  Pitcairn  and  Raymond, 


314 


LEUCORRHCEA  OR  WHITES. 


without  regarding  the  examination  of  the  parts  as  an  infallible  mode, 
think  with  propriety  that  it  may  be  useful  in  making  out  the  diagnosis. 
Benjamin  Bell  placed  the  seat  of  syphilitic  discharges  in  the  canal  of 
the  urethra,  and,  like  M.  Ricord,  advises  pressure  upon  this  canal  from 
behind  forwards  with  the  extremity  of  the  finger;  “we  shall  express 
in  this  way,”  says  this  author,  “the  matter  of  the  syphilitic  infection.” 
But  numerous  and  well-observed  cases  prove  that  the  inductions 
drawn  from  the  presumed  difference  of  seat  deserve  but  slight  con- 
fidence ; the  same  is  true  as  to  the  persistence  of  the  blennorrhagic 
discharge  during  the  flow  of  the  menstruse,  and  the  suspension,  on 
the  other  hand,  of  the  leucorrhoeal  flux  upon  the  appearance  of  men- 
struation. In  fact,  the  signs  indicated  by  Jean  Fernel.*  physician  to 
King  Henry  II,  by  Jean  Liebault,t  Louis  Mercatus,f  Roderic  & Cas- 
tro^ Lazare  Pe,||  Primrose, IF  Mauriceau,**  Charleton,tt  Pierre  Fre- 
sart,f  J and  which  were  regarded  by  Baglivi  §§  as  infallible,  are  just 
as  illusory  as  those  already  mentioned ; for,  with  Baillou,  Astruc  and 
several  other  physicians,  we  have  seen  both  these  sorts  of  discharge 
occurring  at  the  same  time. 

The  pain  which  precedes  a blennorrhagic  discharge,  and  which, 
according  to  Pinel,is  never  present  in  leucorrhoea,  the  sensation  of  heat 
and  smarting  felt  while  urinating,  which  has  been  indicated  by  seve- 
ral authors,  and  especially  by  Charleton,  (loc.  cit.,)  as  a characteristic 
mark  of  syphilitic  discharges,  the  co-existence  of  arthritis  with  vagi- 
nitis, described  by  M.  Ricord,  and  finally  the  pale  red  tint  and  whitish 
and  coppery  spots,  which  M.  Richerand  regards  as  the  marks  of  blen- 
norrhagia  properly  so  called,  are  not  really  pathognomonic  signs 
upon  which  a positive  opinion  as  to  the  nature  of  the  disease  can  be 
safely  made  out. 

The  consistence,  the  different  alterations,  and  the  various  tints  of  the 
utero-vaginal  secretions  are  quite  as  deceitful;  for,  as  M.  Lagneau  has 
said,  “ the  green  or  yellow  colour  of  the  discharge,  its  greater  or  less 
quantity,  its  ever-variable  duration,  the  differences  in  the  intensity  of 
the  inflammation,  are  not  data  sufficient  to  allow  a prudent  physician 
to  pronounce  positively,  for  syphilitic  blennorrhagia  is  often  indolent, 
lasts  but  a short  time,  and  furnishes  little  matter,  the  colour  of  which 
is  almost  always  of  a milky  white ; whilst  we  daily  meet  with  dis- 
charges we  are  compelled  to  regard  as  non-virulent,  presenting  these 
different  phenomena  in  the  most  marked  manner.” 

The  contagious  property  of  the  discharge,  and  its  transmission  by 
coitus,  are  not  better  calculated  for  solving  the  problem  ; for  daily 
experience  shows  that  it  is  possible  to  cohabit  with  a woman 

* La  Pathologie  de  J.  Fernel,  lib.  vi.  cap.  16. 
t De  la  sante,  fecondite  et  maladies  des  femmes,  liv.  v. 
t De  affect,  mulierum,  lib.  i.  cap.  15. 

§ De  morbis  mulierum,  lib.  i.  cap.  4. 

II  Maladies  des  femmes,  liv.  ii.  ch.  36. 

*[  De  morbis  mulierum  et  symptom,  lib.  v. 

**  Maladies  des  femmes,  anat.  des  part.  enit.  chap.  6. 
ff  De  Calam.  et  uteri  rheumatismo,  cap.  8. 

Emmenolog.  cap.  x. 

§§  De  praxi  medica,  lib.  ii.  cap.  8. 


i 

LEUCORRHCEA  OR  WHITES. 


315 


having  syphilitic  blennorrhagia  without  contracting  the  same  disease, 
whilst  leucorrhoea  may  become  so  irritating  as  to  communicate  an 
acute  blennorrhagia.  The  age,  the  moral  character  of  the  patient, 
and  the  antecedents  may  likewise  lead  to  error.  Mauriceau  states 
that  three  little  girls,  the  eldest  of  whom  was  only  nine  years  old, 
were  brought  to  him,  supposed  to  have  lluor  albus.  He  having 
interrogated  them,  soon  convinced  himself  by  their  answers,  not- 
withstanding the  absence  of  all  violence  upon  the  genital  parts,  that 
they  had  been  infected  by  some  wicked  domestics. 

From  what  we  have  now  said,  it  is  easy  to  see  that  the  signs 
proper  to  distinguish  a true  leucorrhoeal  discharge  from  one  depend- 
ent upon  syphilitic  blennorrhagia,  have  always  presented  the  great- 
est uncertainty  even  to  the  most  experienced  practitioners.  Cullerier, 
whose  opinions  upon  this  matter  are  of  the  hightest  value,  leaves 
the  question  undecided.  M.  Ricord,  who,  by  his  excellent  judgment 
and  varied  observation,  is  better  fitted  to  decide  upon  this  subject 
than  any  one  else,  does  not  conceal  his  embarrassment ; for,  he  says, 
in  one  of  his  memoirs,  “ that  without  the  actual  existence  of  conse- 
cutive symptoms,  which,  moreover,  must  be  fully  ascertained,  we 
remain  in  the  greatest  uncertainty  as  to  the  diagnosis,  being  able  in 
reality  merely  to  recognize  the  physical  alteration  of  the  parts  and 
their  secretions,  without  having  the  power  of  learning  the  intimate 
nature  or  essence  df  the  disease,  if  we  may  so  express  it,  and  finding 
ourselves  reduced  to  the  detection  of  the  existence  of  an  urethritis, 
vaginitis,  or  uterine  catarrh,  while  beyond  this  all  is  probability,  and 
very  often  error.”  Sauvages,  in  his  Methodical  Nosology , (class  10,) 
also  concluded  that  Medicine  supplies  no  certain  signs  by  which  to 
distinguish  gonorrhoeal  discharges  from  the  leucorrhoeal  secretion, 
properly  so  called:  nec  dantur  limites  qui  genus  gonorrhese  in 
mulieribns  h leucorrhed  discernant. 

The  uncertainty  which,  for  so  long  a period,  has  prevailed  as  to  the 
diagnosis  of  the  discharge  from  the  genital  organs  of  the  female,  has 
just  been  removed  in  great  part  by  the  researches,  as  novel  as  they 
are  ingenious,  to  which  Dr.  Donne,  ex-chief  of  the  Clinic  of  the  Faculty 
of  Medicine  of  Paris,  has  been  recently  devoting  himself.  As  it  is  of 
the  greatest  importance  for  the  therapeutical,  and  often  for  the  moral 
interests  of  the  patient,  dearer  still  than  those  of  health,  to  remove 
all  uncertainty  as  to  the  nature  of  utero-vaginal  secretions,  we  shall 
proceed  to  point  out  in  few  words  the  differential  signs,  mentioned  in 
the  excellent  memoir,'*  published  by  the  young  physician  we  have 
just  cited. 

In  venereal  blennorrhagia  the  discharge  is  always  purulent,  that 
is  to  say,  a certain  quantity  of  pus  is  mixed  with  the  proper  mucus 
of  the  vagina.  In  this  condition  the  secreted  matter  contains  a mul- 
titude of  animalcules,  edited  by  M.  Donne,  vaginal  trico-monas , 
which  are  discovered  by  placing  a drop  of  the  muco-purulent  fluid 
between  two  fine  glasses,  and  examining  them  with  a microscope, 

* Recherches  microscopiques  sur  la  nature  du  mucus  et  la  matiere  des  divers 
ecoulements  des  organes  genitaux-urinaires  chez  1’homme  et  chez  la  femme-  Paris, 
1837. 


316 


X.EUCORRHCEA  or  whites. 


magnifying  from  two  hundred  and  fifty  to  three  hundred  times. 
These  infusory  animals,  whose  bodies  are  transparent,  and  of  round 
or  oval  form,  with  a diameter  of  to  -£$  of  a millimeter,  are  most 
commonly  united  in  groups  of  from  two  to  six  individuals.  When 
examined  with  the  light  of  a lamp,  they  may  sometimes  be  seen 
to  move,  more  especially  to  agitate  in  every  direction  a long  filiform 
and  very  delicate  appendage,  which  serves  to  distinguish  them  from 
the  spherical  and  inanimate  globules  of  true  phlegmonous  pus,  in 
which  they  are  never  observed  to  exist. 

The  discharge  of  true  leucorrhoea  is  thick,  creamy,  and  does  not 
stick  to  the  fingers  ; it  reddens  litmus  paper,  and  seems'  to  be  com- 
posed of  little  oval  bodies,  having  the  appearance  of  pellicles  or 
scales  from  the  mucous  membrane ; finally,  it  never  contains  the 
infusory  animalcules  found  only  in  syphilitic  discharges,  and  besides, 
ammonia  gives  it  a slimy  and  ropy  consistence  when  it  is  mixed  with 
pus,  which  does  not  occur  in  the  contrary  case.  If  the  muco-puru- 
lent  discharge  be  occasioned  either  by  the  presence  of  a foreign  body 
in  the  genital  cavities,  by  an  irritating  injection,  or  any  other  local 
cause  of  inflammation,  independent  of  the  venereal  virus,  the  trico- 
monas  is  never  developed,  although  the  secreted  matter  then  resem- 
bles that  of  the  syphilitic  blennorrhagia,  that  is  to  say,  when  treated 
with  ammonia,  it  assumes  a viscid,  tenacious  and  ropy  appearance. 

To  distinguish  vaginal  from  uterine  mucus,  it  is  sufficient  to  know 
that  the  former  is  not  only  thick,  creamy  and  never  ropy,  but  also 
that  it  is  acid,  and  that  it  reddens  litmus  paper,  while  mucus  secreted 
by  the  womb  is  always  alkaline,  returns  the  blue  colour  of  litmus 
paper,  turns  the  syrup  of  violets  green,  and  finally,  has  such  a slimy, 
ropy  and  tenacious  consistence,  that  it  is  with  great  difficulty  it  can 
be  detached  from  the  margin  of  the  os  uteri.  Such,  in  a few  words, 
are  the  means  of  diagnosis,  pointed  out  by  M.  Donne,  whose  memoir 
we  recommend.  In  it  will  be  found  related,  with  as  much  detail 
as  clearness,  the  results  of  the  interesting  researches  he  has  made 
upon  this  subject. 

If  the  discharge  proceed  from  a cancer,  an  abscess,  a polypous 
tumour,  or  any  other  organic  lesion  of  the  womb  or  vagina,  we 
might  easily  make  the  diagnosis  by  a consideration  of  the  symptoms 
proper  to  these  affections,  and  especially  by  the  exploration  of  the 
parts  by  the  Touch  and  the  speculum. 

The  prognosis  of  leucorrhoea  depends  upon  the  cause,  the  duration 
of  the  discharge,  its  quantity,  the  complications,  the  strength  of  the 
female,  her  age,  temperament,  and  finally,  the  hygienic  condition  in 
which  she  may  be  placed.  Where  the  cause  is  a permanent  one, 
such,  for  example,  as  the  presence  of  a pessary  in  the  vagina,  the 
use  of  foot-stoves,  of  coffee,  of  unhealthy  aliment,  a moral  affection, 
&c.,  the  removal  of  the  cause  is  soon  followed  by  a cure,  unless  the 
disease  persist  from  the  habit  of  fluxionary  movement,  which  then 
renders  the  case  more  uncertain  and  more  difficult.  Leucorrhcca, 
coming  on  in  the  subacute  form,  is  also  easier  to  cure ; in  general, 
the  older  the  discharge,  the  less  are  the  chances  of  cure ; in  women 


LEUCORRHCEA  OR  WHITES. 


317 


of  advanced  age,  it  is  almost  always  incurable,  which  fact  justifies 
the  unfavourable  prognosis  made  by  Hippocrates,  when  he  said : 
(De  Morb.  Mu  tier.)  hie  Jluor  senioribus  prope  incur abilis  est , et 
eas  usque  ad  mortem  comitatur.  If  the  leucorrhoeal  flux  be  abun- 
dant and  accompanied  by  numerous  sympathetic  phenomena,  if  it 
date  from  several  years  back,  if  it  seem  to  be  hereditary  and  consti- 
tutional, or  finally,  if  it  be  complicated  with  cachexia,  with  scrofula, 
or  with  herpetic  affections,  the  progress  of  the  disease  is  difficult  to 
arrest,  and  it  often  proves  rebellious  under  all  the  means  opposed 
to  it. 

After  death  we  generally  find  the  vagino-uterine  mucous  mem- 
brane softened  and  swollen  ; the  os  tincae  is  dilated,  reddish,  soft  and 
hypertrophied  ; the  mucous  membrane  covering  the  vagina  and  vulva 
presents  a slaty  or  bluish  tint;  when  compressed  there  oozes  from 
all  parts  a fluid  analogous  to  that  which  was  secreted  during  life. 
The  surface  of  the  uterine  cavity  is  overspread  with  little  vesicles 
filled  with  a sero-mueous  fluid ; the  membrane  which  lines  it,  com- 
monly soft,  loose  and  infiltrated,  is  sometimes  marked  by  dilated 
vessels,  and  exhibits  ulcerations,  erosions,  or,  more  rarely,  it  has  the 
aspect  of  a cartilage,  and  is  covered  in  several  places  with  gan- 
grenous spots. 

Before  entering  upon  the  treatment  of  leucorrhoea,  let  us  add  a few 
words  as  to  its  more  or  less  sudden  suppression,  and  the  accidents 
resulting  therefrom. 

The  suppression  of  a leucorrhoeal  discharge  may  take  place  sud- 
denly, as  an  effect  of  different  physical  causes,  as  the  use  of  astring- 
ents taken  internally  or  applied  locally  to  the  genital  organs;  of  an 
emetic,  of  purgatives,  of  cold  baths,  the  application  of  ice,  the  in- 
vasion of  another  disease ; finally,  the  intemperate  use  of  a number 
of  panaceas,  whose  grotesque  titles  with  impunity  disgrace  the 
columns  of  our  journals  and  the  walls  of  all  our  houses. 

The  dangers  of  a suppression  of  a vagino-uterine  discharge  are 
the  more  serious  as  the  secretion  is  more  abundant,  and  especially 
of  longer  standing.  Although  we  should  have  to  prepare  an  almost 
complete  nosographical  table  in  order  to  enumerate  all  the  disorders 
which,  according  to  most  authors,  might  follow  suppression  of  the 
leucorrhoeal  discharge,  we  believe  that  these  disorders  are  much 
exaggerated,  and  that  it  is  wrong  to  persuade  women  that  their 
disgusting  infirmity  is  a salutary  emunctory,  the  very  guarantee  of 
their  health.  Let  it  not  be  supposed,  however,  that  we  believe  it 
possible  to  suppress  an  ancient  and  abundant  secretion  suddenly  with- 
out inconvenience,  for  we  are  as  far  removed  from  the  audacity  oi 
empiricism,  as  from  the  timidity  of  ignorance.  Our  intention  is  merely 
to  reduce  to  their  just  value  the  exaggerated  fears  of  practitioners, 
and  to  prove  to  them  that  while  we  believe  the  cure  of  leucorrhoea 
ought  to  be  undertaken,  we  are  perfectly  convinced  that  a true  cure 
cannot  be  obtained  except  by  acting  in  a gradual  manner,  and  by 
insensibly  restoring  the  economy  to  its  normal  state.  It  is,  in  our 
opinion,  the  more  necessary  not  to  abandon  this  disease  to  itself,  be- 
cause it  not  only  compromises  the  reproduction  of  the  species,  but  may 


318 


LEUCORRHCEA  OR  WHITES. 


also  lead  to  unfortunate  moral  consequences,  and  often  does  become 
the  source  of  very  serious  alterations. 

Besides,  if,  while  acting  prudently  and  rationally,  accidents  should 
happen  to  occur,  we  could  always  treat  them  and  arrest  their  pro- 
gress as  soon  as  they  appear. 

The  treatment  of  leucorrhoea  ought  necessarily  to  differ,  as  occur- 
ring in  the  subacute  or  active  form,  and  in  the  chronic  or  passive  form. 

In  the  subacute  form  we  ought,  especially  if  the  disease  be  recent, 
and  the  female  young  and  plethoric,  to  resort  to  general  bleeding, 
which  acts,  either  as  a derivative  or  by  lessening  the  fluxionary 
movement  which  tends  to  localize  itself  upon  the  genital  mucous 
membrane ; it  is  necessary,  however,  to  employ  sanguine  evacua- 
tions with  prudence  and  care,  or  instead  of  diminishing  the  general 
susceptibility,  we  might  often  produce  debility,  and  run  the  risk  of 
forcing  a subacute  leucorrhoea  near  its  term  of  resolution,  to  assume 
a chronic  and  passive  type. 

Among  the  means  which  serve  to  increase  the  effect  of  small  gene- 
ral bleedings,  and  which,  in  most  cases,  are  sufficient  of  themselves 
to  moderate  or  entirely  remove  the  inflammation,  we  include  a more 
or  less  strict  abstinence;  diluent,  mucilaginous, and  acidulated  drinks; 
emulsions,  and  especially  decoctions  of  hemp-seed  with  nitre ; emol- 
lient and  opiate  injections;  enemata  and  poultices  of  the  same  nature; 
and  continuous  irrigations  made  by  means  of  a large  curved  canula 
introduced  into  the  vagina.  To  avoid  the  irritating  effect  of  a jet  of 
the  medicated  fluid,  we  employ  a tin  or  gum-elastic  canula,  the  end 
of  which,  being  pierced  with  a great  number  of  holes,  contains  a 
small  sponge  with  a ribbon  attached  to  it,  by  which  to  withdraw  and 
renew  it  as  often  as  may  be  necessary. 

If  the  local  inflammatory  symptoms  refuse  to  yield  to  the  measures 
now  indicated,  we  may  have  recourse  to  applications  of  leeches 
about  the  margin  of  the  anus,  especially  if  there  be  hemorrhoids,  or 
to  the  vulva  in  cases  of  amenorrhoea;  finally,  should  the  disease 
prove  very  obstinate,  we  must  establish  a revulsive  movement 
towards  the  intestinal  mucous  membrane  by  the  use  of  purgatives, 
such  for  example  as  rhubarb,  which  is  at  the  same  time  purgative, 
tonic  and  astringent.  Goliken  and  Riverius  obtained  great  advan- 
tages from  the  use  of  it;  and  Hippocrates,  Forestus,  Sydenham, 
Ettmuller,  and  many  other  physicians,  had  a like  success  from  the 
employment  of  drastic  purgatives.  It  was  to  the  application  of  this 
derivative  method  that  Galen  * owed  the  brilliant  success  which 

* De  Praecognit  ad  Posthum.,  cap.  8.  The  father  of  medicine,  who  was  acquainted 
with  the ‘sympathetic  relation  connecting  the  stomach  and  womb,  likewise  prescribed 
emetics  in  the  treatment  of  fluor  albus,  provided  the  patients  were  still  young  and  re- 
tained sufficient  strength.  Ettmuller,  Fonseca,  Hoffman,  and  some  other  physicians, 
have  also  recommended  them;  Doctor  Rast,  of  Lyons,  treated  all  cases  of  leucor- 
rhoea  by  the  use  of  ipecacuanha,  administered  in  minute  doses,  and  Barthez  frequently 
pursued  this  method  with  like  confidence.  Though  we  deem  it  improper  to  resort  to 
such  energetic  remedies  without  much  reserve,  we  are  of  opinion  that  the  physicians 
of  the  present  period  err  in  rejecting  them  altogether;  and  we  believe,  judging  from 
our  own  observation  and  from  a large  number  of  cases  collected  by  various  authors, 
that  gentle  emetics,  managed  with  skill,  and  repeated  at  suitable  intervals,  are  really 
useful  in  cases  that  prove  rebellious  to  antiphlogistic  remedies. 


LEUCORRHCEA  OR  WHITES. 


319 


spread  his  renown  even  to  the  palace  of  Marcus  Aurelius.  This 
celebrated  physician  of  ancient  times,  by  the  use  of  purgatives,  diu- 
retics, and  frictions  over  the  whole  surface  of  the  body,  very  speedily 
cured  the  wife  of  Boethus,  suffering  from  a profuse  leucorrhoea,  which 
the  skill  of  the  first  physicians  of  Rome  had  failed  to  relieve. 

The  utility  of  derivatives  to  the  surface  is  perhaps  more  clearly 
established  than  that  of  derivatives  to  the  intestinal  mucous  mem- 
brane, and  it  is,  no  doubt,  for  this  reason  that  modern  practitioners 
more  frequently  resort  to  the  former  method  than  to  the  latter. 
Diaphoretics,  which  are  indicated  by  several  of  the  causes  of  the  dis- 
ease, should  be  employed  conjointly  with  stimulating  and  aromatic 
frictions,  and  the  use  of  warm  clothing  and  flannel  to  the  skin. 
Should  we  find  it  necessary  to  determine  a cutaneous  irritation,  as 
derivative  from  the  utero-vaginal  inflammation,  and  powerful  enough 
to  recall  to  the  exterior  surface  any  eruption  to  whose  suppression 
might  be  attributed  the  existence  and  obstinacy  of  the  discharge,  we 
might  resort  to  mustard  poultices,  to  moxas  applied  upon  the  pelvis, 
and  to  flying  or  permanent  blisters.  Permanent  exutories  answer  the 
double  end  in  this  case  of  causing  revulsion  from  the  genital  mucous 
membrane,  and  of  being  at  the  same  time  supplementary  to  the 
leucorrhceal  discharge.  In  fine,  the  treatment  of  subacute  leucor- 
rhoea presents  two  well  marked  periods;  the  first  comprises  the 
employment  of  antiphlogistics  so  long  as  there  are  inflammatory 
symptoms,  and  the  second  the  use  of  derivatives  conjointly  with 
revellents.  During  this  second  period  we  ought  not  only  to  allow  a 
more  nutritious  food,  but  we  should  even  prescribe  some  light  tonics, 
such  as  bark,  gentian,  extract  of  centaurea  benedicta,  and  rhubarb  in 
small  doses,  infusions  of  common  European  centaury,  of  sage,  balm, 
etc.  We  should  likewise  try  slightly  astringent  injections,  such  as  a 
mixture  of  water  and  red  wine,  sweetened  aluminous  water,  acetate 
of  lead,  sulphate  of  zinc,  etc.,  gradually  rendered  more  and  more  active. 
It  would  be  well  to  recur  also  to  balsamic  substances,  for  instance,  tolu, 
cubebs,  turpentine,  and  infusion  of  the  cones  of  the  European  silver  fir. 
The  balsam  of  copaiba  has  always  answered  best  in  our  hands,  whe- 
ther because  we  administer  it  in  the  form  of  sugar-plums*  and  of 
pills,  or  because  we  employ  it  in  small  enemata  or  in  the  form  of 
suppositories  prepared  in  the  manner  we  shall  presently  describe.  By 
the  methodical  use  of  these  remedies,  the  disease  is  almost  always 
soon  overcome,  and  a radical  cure  obtained.  But  in  order  to  attain 
this  fortunate  result,  we  must  always  favour  the  action  of  the  thera- 
peutical agents  by  the  absolute  repose  of  the  genital  organs,  by 
attention  to  hygieine,  and  especially  by  the  indispensable  precaution 
of  avoiding  all  kinds  of  excess  or  changes  of  regimen,  which  would 
not  only  prove  a continual  source  of  irritation,  but  would  also  renew 
the  inflammation,  where  we  had  succeeded  in  quelling  it. 

* We  addressed,  six  years  since,  to  the  Academy  of  Medicine,  two  memoirs  on  the 
copaiba  and  its  preparation  in  the  form  of  dragees  (sugar-plums)  without  disagreeable 
odour  or  taste.  Administered  according  to  our  formula,  this  remedy  does  not  disgust 
the  patient,  causes  no  cholic,  and  acts  in  a more  efficacious  manner  than  in  any  other 
form. 


320 


LEUCORRHCEA  OR  WHITES. 


An  entirely  different  method  of  treatment  should  be  adopted  where 
the  leucorrhcca  is  of  the  passive  form,  whether  it  has  succeeded  to 
some  preceding  type,  or  whether  it  be  primitive,  as  for  instance, 
when  coincident  with  chronic  amenorrhoea,  with  chlorosis  or  with 
relaxation  of  the  sexual  organs,  due  to  a lymphatic  constitution,  to 
numerous  pregnancies,  or  excessive  coitus  and  masturbation,  espe- 
cially when  these  occur  in  women  advancing  in  years. 

As  the  genital  cavities  are  but  slightly  sensitive  in  passive  chronic 
leucorrhoea,  we  should  always  assure  ourselves  by  the  Touch  and 
the  speculum,  whether  the  discharge  is  really  idiopathic,  or  whether 
it  is  symptomatic  of  some  alteration  of  tissue,  or  some  lesion  of  the 
vagina  or  neck  of  the  womb.  Should  ulcerations  or  erosions  exist, 
they  must  be  cauterized  with  the  acid  nitrate  of  mercury,  observing 
the  rules  and  precautions  presently  to  be  mentioned.  W e must  act 
in  the  same  manner  if  small  vegetations  be  found,  but  if  large,  they 
must  be  excised  by  some  of  the  methods  to  be  described  hereafter. 
When  the  mucous  membrane  is  found  infiltrated  or  indurated,  resort 
must  be  had  to  revellent  frictions  with  ointment  of  hydriodate  of  pot- 
ash, or  mercurial  ointment  on  the  hypogastric  region  or  on  the  inside 
of  the  thighs ; and  if  the  patient  can  bear  it,  a large  plug  of  charpie, 
covered  with  a layer  of  mercurial  ointment,  may  be  introduced  into 
the  vagina. 

When  leucorrhoea  becomes  chronic  and  passive,  it  is  not  a mere 
local  alteration  that  we  have  to  treat,  but  the  whole  economy  which 
is  to  be  modified  and  restored  to  its  normal  condition.  The  object 
we  must  then  seek  is  to  dry  up  a morbid  discharge,  which  is,  at 
one  and  the  same  time,  the  cause  and  effect  of  the  general  and  local 
debility,  by  reconstituting,  so  to  speak,  and  giving  tone  to  the  various 
functions  which  are  in  a more  or  less  perverted  condition. 

For  this  purpose  experience  has  shown  the  efficacy  of  gentian,  of 
rhubarb  in  small  doses,  and  particularly  of  cinchona,  which  acts  as 
a tonic,  and  perhaps  also  by  interrupting  the  habit  of  the  discharge. 
We  have  also  tested  the  happy  effects  of  the  infusions  of  absinthium 
recommended  by  Professor  Alibert;  of  the  extract  of  centaurea  bene- 
dicta,  which  forms  the  basis  of  the  anti-leueorrhoeal  pills,  upon  which 
Stahl  pronounces  so  pompous  an  eulogium ; of  steel  filings  mixed 
with  myrrh,  from  which  Halle  obtained  great  advantages;  of  the 
ferruginous  acidulated  mineral  waters,  of  Forges,  Spa,  Vichy,  Pou- 
gue  and  Passy ; and  of  different  martial  preparations,  amongst  others 
the  sub-carbonate  and  hydriodate  of  iron,  but  chiefly  the  black 
oxide  of  that  metal,  in  doses  of  from  three  to  six  grains  daily.  Of 
the  preparations  administered  internally,  no  one  has  been  more  con- 
stantly successful  in  our  hands  than  the  anti-leucorrhoeal  troches  of 
copaiba,  which  formed  the  subject  of  a memoir,  presented  by  us  to 
the  Royal  Academy  of  Medicine,  in  1832.  The  dose  of  our  balsa- 
mic troches  is  eighteen  per  diem,  six  early  in  the  morning,  four  in  the 
course  of  the  day,  and  eight  in  the  evening  upon  going  to  bed. 
The  number  may  be  increased  to  thirty,  and  even  forty,  taken  at 
three  different  times  ; but  all  the  inflammatory  symptoms  must  first 
have  disappeared,  and  it  is  for  this  reason  patients  should  never  employ 


LEUCORRHCE A OR  WHITES. 


321 


them,  without  the  preliminary  advice  of  an  enlightened  physician, 
who  can  decide  as  togthe  propriety  of  using  them. 

The  copaiba  may  also  be  administered  by  the  rectum,  in  the  mode 
proposed  by  Professor  Velpeau,*  who  prescribes  it  in  small  ene- 
mata,  prepared  with  six  ounces  of  mucilage  of  marsh-mallow  or  flax- 
seed, and  from  four  to  six  drachms  of  copaiba  mixed  with  the  yolk 
of  an  egg,  with  the  addition  of  a grain  of  gummy  extract  of  opium. 
These  balsamic  enemata  ought  to  be  retained.  The  quantity  of 
copaiba  may  be  gradually  increased  to  an  ounce,  and  even  an  ounce 
and  a half,  according  to  the  degree  of  sensibility,  which  is  different 
in  different  individuals.  It  may  likewise  be  used,  as  we  have  em- 
ployed it  for  a long  time,  in  the  form  of  suppositories,  which  we  pre- 
scribe according  to  the  following  formula  : 


Balsam  of  copaiba, 

Beuerre  de  cacao, 

Solid  resin  of  copaiba, 

Gummy  extract  of  opium,  gr.  ss. 

To  be  made  into  a suppository. 


The  anti-blennorrhagic  and  anti-leucorrhoeal  suppositories  should 
be  used  twice  daily,  in  the  morning,  and  at  bed-time.t 

To  these  means  should  be  added  the  use  of  tonic  and  slightly  as- 
tringent injections,  consisting  either  of  a mixture  of  water  and  sweet- 
ened wine,  of  decoction  of  bistort  root,  pomegranate  bark,  or  a very 
weak  solution  of  sugar  of  lead  or  sulphate  of  zinc  ; these  last  injec- 
tions should  be  used  with  care,  in  order  to  avoid  too  sudden  suppres- 
sion, and  with  the  precautions  that  we  mentioned  while  speaking  of 
subacute  leucorrhma,  after  the  example  of  Dr.  Fleetwood  Churchill, 
of  Dublin,  we  might  also  make  use  of  vaginal  injections  consisting 
of  a solution  of  nitrate  of  silver,  in  the  proportion  of  a grain  to  an 
ounce  of  distilled  water  ; while,  however,  augmenting  progressively 
the  quantity  of  the  salt,  we  think  it  would  be  dangerous  to  carry  it 
so  high  as  the  Irish  physician  recommends.^ 

* Researches  and  observations  upon  the  employment  of  copaiba,  etc.:  administered 
per  anum  in  blennorrhagia.  (Archives  Gen.  de  Med.,  tom.  xiii.  p.  33, 1827.) 

f Doctor  Donne  has  also  used  the  copaiba  in  the  form  of  suppositories;  though  his 
formula  differs  but  little  from  our  own,  we  feel  convinced  that  our  worthy  fellow 
practitioner  was  acquainted  with  our  two  memoirs  on  copaiba. 

t Dr.  Ricord  employs  the  solid  nitrate  of  silver,  which  he  fixes  in  the  slender 
blades  of  a pair  of  elastic  forceps,  so  arranged  as  to  grasp  the  caustic  uniformly,  as 
it  dissolves,  without  allowing  of  its  direct  action  upon  the  vaginal  or  uterine  mucous 
membranes,  through  the  lateral  openings  of  the  instrument.  Six  or  eight  hours  after 
the  cauterization,  the  patient  should  use  injections  of  cold  water,  to  be  continued 
until  the  time  for  a new  application  of  the  nitrate  of  silver  arrives,  if  this  should  be 
deemed  necessary.  When  an  examination  of  the  diseased  surfaces,  and  of  the  state 
of  the  secretion,  shows  that  a sufficient  change  has  been  brought  about,  a tampon  of 
dry  charpie  is  introduced  into  the  vagina,  in  order  to  separate  the  walls  of  that  canal, 
which  are  then  promptly  restored  to  their  normal  state.  We  ought  to  add,  that  M. 
Ricord  exposes  the  organs  of  generation  by  means  of  a speculum,  and  that  he  caute- 
rizes first  the  uterine  mucous  membrane,  then  returning  to  the  neck,  he  carries  the 
caustic  rapidly  from  the  summit  to  the  base,  circularly,  as  well  as  over  the  whole 
vaginal  mucous  membrane,  by  bringing  the  instrument  rapidly  towards  himself,  as 
far  as  the  vulva.  Finally,  in  order  to  procure  an  immediate  application,  he  is  care- 
ful first  to  wash  the  surfaces  with  suitable  injections.  When  the  mouth  of  the  uterus 


21 


322 


LEUCORRHCEA  OR  WHITES. 


In  order  to  keep  up  a continuous  action,  Doctor  Ricord  uses  tam- 
pons of  soft  charpie  or  fine  sponge,  impregnate^  with  aromatic  wine, 
with  an  astringent  decoction,  or  with  Goulard’s  lotion,  carefully  in- 
troduced to  the  bottom  of  the  vagina,  either  with  the  index  finger,  or 
by  means  of  the  speculum ; he  then  administers  another  injection  in 
order  to  moisten  the  vaginal  plug  throughout,  which  are  allowed  to 
remain,  and  which  should  merely  fill  up  without  distending  the  vulvo- 
uterine  canal. 

In  the  employment  of  this  tonic  and  astringent  medication,  it  is 
necessary  to  be  careful  not  to  exceed  a proper  degree  of  stimulation, 
and  to  be  always  prepared  to  arrest  its  effects  by  means  of  sedatives, 
baths,  and  the  antiphlogistic  remedies. 

As  it  would  be  useless  in  this  place  to  cite  all  the  substances  which 
have  been  advantageously  employed  in  the  treatment  of  leucorrhoea, 
we  shall  rest  content  with  mentioning  those  that  have  enjoyed  or 
still  possess  most  credit;  for  example,  myrrh,  incense,  mastich,  the 
balsams  of  copaiba  and  tolu,  powdered  cubebs,  the  cones  of  the 
northern  fir,  turpentine,  ergot,  recently  employed  by  MM.  Bazoni, 
Negri,  Hatin,  Dufrenois  and  Bocquet;  finally  the  distilled  cherry- 
laurel  water,  used  both  internally  and  by  injection,  by  Doctor  Caron 
du  Villars;  the  cicuta,  recommended  by  Storck  and  Quarin ; and 
opium,  which  several  practitioners  have  found  serviceable,  amongst 
whom  M.  Alibert,  especially  when  nervous  symptoms  and  hysterical 
spasms  were  present. 

In  spite  of  the  careful  employment  of  the  curative  means  just  enu- 
merated, leucorrhoea  often  resists  the  efforts  of  the  physician,  unless 
he  be  seconded  by  the  patient  and  by  proper  attention  to  hygieine. 
The  regimen  should  be  directed  on  the  same  principles  as  the  medi- 
cines, that  is  to  say,  it  should  be  fortifying  without  being  irritating ; 
the  clothing  must  be  warm,  and  flannel  next  to  the  skin  ought  to  be 
recommended  ; we  should  advise  a residence  in  the  country  in  a pure 
and  healthy  air,  especially  in  the  summer  season,  which  means  have 
been  known  to  dispel  a chronic  leucorrhosa  very  speedily,  which,  how- 
ever has  again  appeared  at  the  approach  of  winter  or  on  returning 
to  the  city.  The  patient  should  use  all  her  endeavours  to  overcome 
certain  inclinations  and  illicit  habits,  which  are  frequently  the  chief 
and  unknown  cause  of  her  sad  and  disgusting  malady.  She  should 
compel  herself  to  take  muscular  exercise  without  carrying  it  to  fa- 
tigue, which  will  dispose  her  to  take  food  at  first  light  and  of  easy 
digestion,  and  then  more  abundant  and  more  substantial. 

We  shall  conclude  by  saying  that  the  approach  of  the  first  men- 
struation, the  pregnant  state,  and  the  critical  age,  are  so  many  causes 
which  should  not  be  rashly  interfered  with.  Prudence  demands  that 

is  not  large  enough  to  allow  of  the  introduction  of  the  nitrate  of  silver,  M.  Ricord  has 
recourse  to  caustic  injections  made  with  the  double-acting  syringe,  described  in  the 
memoir  on  blennorrhagia,  presented  by  him  to  the  Academy  of  Medicine.  This 
method  has  been  employed  a great  number  of  times  for  discharges  which  had  resisted 
general  medication  and  local  agents;  for  cauterizing  ihe  vaginal  mucous  membrane, 
the  proper  method  is  to  use  a small  sponge  impregnated  with  a concentrated  solution 
of  nitrate  of  silver,  and  fixed  on  the  extremity  of  a little  shank  of  wood,  or  on  our 
caustic-holder. 


LEUCORRHCEA  OR  WHITES. 


323 


we  should  wait  until  their  influence  is  no  longer  felt,  and  that  we 
should  also  respect  the  critical  discharges,  for  fear  of  recalling  the 
disease,  of  which  they  are  the  substitutes.  It  is  not  proper  to  cure 
leucorrhma  except  where  it  persists  after  the  primary  affection,  and 
besides,  we  should  always  take  the  precaution  to  prevent,  as  far  as 
possible,  a recession,  by  means  of  an  issue,  and  by  the  use  of  saline 
purgatives. 

Such  is  a sketch  of  the  numerous  resources  of  medicine  in  leu- 
corrhoeal  discharges,  the  treatment  of  which  would  doubtless  be 
more  successful  if  a bolder  and  more  energetic  therapeia,  always 
based,  however,  on  reason  and  the  nature  of  the  disease,  were  re- 
sorted to. 

% 

OF  REDNESS,  SIMPLE  ULCERATIONS,  AND  ERUPTIONS  UPON  THE  OS 

TINCJ3. 

Chronic  metritis,  accompanied  with  profuse  discharge,  is  almost 
always  followed  by  softening  of  the  uterine  mucous  membrane,  and 
sometimes  by  the  development  upon  the  os  tincse  of  red  spots,  exco- 
riations, granulations,  vegetations  and  different  degenerations,  which 
we  shall  proceed  to  pass  in  review. 

The  permanent  contact  of  fluid  secreted  by  the  uterus  determines 
a redness  of  the  posterior  lip  chiefly,  which  is  of  no  importance  in 
itself,  but  which  may  become  the  germ  of  more  dangerous  altera- 
tions. These  reddish  spots,  which  sometimes  extend  to  the  vaginal 
mucous  membrane,  are  disposed  in  groups  resembling  the  vivid  red- 
ness of  herpetic  inflammation,  observed  most  frequently  upon  the 
face.  In  some  women,  they  consist  of  small  distinct  points  like 
flea-bites,  and  give  to  the  mucous  membrane,  as  M.  Lisfranc  ob- 
serves, the  appearance  of  the  skin  of  a salmon  trout.  In  other  cases, 
the  cervix  uteri  is  the  seat  of  a superficial  ulceration  which  at  first 
destroys  only  the  mucous  layer  of  the  cervix  to  a greater  or  less  ex- 
tent; M.  Dupuytren  said,  in  his  Lecons  Or  ales  y that  this  affection 
might  easily  be  misunderstood  if  we  contented  ourselves  with  an  ex- 
ploration made  with  the  finger,  and  that  unless  the  disease  were 
brought  into  view  by  means  of  the  speculum,  we  might  suppose  the 
presence  of  a deep  cancer  of  the  organ.  When  the  os  tincae  and  cervix 
are  engaged  in  the  superior  portion  of  the  instrument,  we  perceive  a 
superficial  ulceration  on  one  of  the  lips,  or  upon  the  external  face 
of  the  cervix  a reddish  ulceration,  which  looks  as  though  it  had  been 
made  with  a punch,  confined  to  the  mucous  membrane,  and  which 
we  know  not  what  better  to  compare  to  than  to  ozaena  of  the  nasal 
fossae;  an  ulceration,  nevertheless,  which  finally  produces  the  death 
of  the  patient,  unless  relief  is  afforded. 

When  the  nature  of  the  affection  is  clearly  ascertained,  a cure  is 
easily  obtained  by  local  bleeding  at  first,  particularly  if  the  female  is 
young  and  the  cervix  very  painful;  then  by  baths,  emollient  injections, 
and  cauterization  with  the  acid  nitrate  of  mercury,  practised  in  the 
manner  we  shall  explain  after  a time.  It  is  proper  to  state,  how- 
ever, that  this  operation  must  be  repeated  until  the  cicatrization  is 


324  REDNESS,  ULCERATIONS,  ERUPTIONS  ON  OS  TINC.E. 

complete.  Doctor  Jobert,  in  a memoir  on  cauterization,*  states  that 
he  has  seen  Professor  Marjolin  repeat  it  as  often  as  twenty  different 
times.  In  such  cases  we  have  never  found  it  necessary  to  repeat  the 
operation  more  than  five  times,  and  most  commonly  two  cauteriza- 
tions have  been  sufficient. 

There  is  another  superficial  lesion  of  the  os  tincae,  which  has  been 
carefully  observed  and  described  by  Madame  Boivin  and  M.  Duges. 
This  affection,  easily  misunderstood  if  examined  by  the  touch  alone, 
is  accompanied  by  a whitish  discharge  from  the  vulva,  and  some- 
times by  pruritus  of  the  sexual  organs,  which  may  go  to  the  extent 
almost  of  producing  nymphomania.  This  pathological  condition,  de- 
signated by  the  term  gran  ulation  of  the  os  tincse , is  characterized  by 
the  presence  of  more  or  less  numerous  elevations  on  the  circumference 
of  the  uterine  orifice.  These  elevations,  which  the  speculum  alone 
enables  us  to  observe  accurately,  are  of  variable  form  and  dimen- 
sions : they  are  commonly  numerous,  of  the  size  of  a millet  seed, 
of  whitish  colour,  of  soft  consistence,  of  a vesicular  appearance,  and 
always  without  pedicles ; at  other  times  they  are  pediculated,  as  it 
were,  few  in  number,  red,  and  offer  some  resemblance  to  certain 
venereal  vegetations ; finally,  there  are  some  which  present  them- 
selves in  the  form  of  small  hard  seeds,  occupying  only  the  extreme 
superficies  of  the  organ,  and  others,  which  are  pretty  large,  but  so 
flat,  as  to  be  scarcely  perceptible  to  the  touch. 

Though  these  forms  of  miliary  and  phlyctenoid  eruptions  may  ter- 
minate without  leaving  any  solution  of  continuity,  their  rupture  often 
occasions  small  superficial  ulcerations,  which,  by  running  together, 
sometimes  end  by  forming  a single  ulcer. 

Granulations  of  the  mucous  membrane  of  the  os  tincae,  as  well  as 
redness  and  superficial  ulcerations  of  that  organ,  generally  begin 
with  the  more  or  less  acute  symptoms  of  simple  chronic  metritis ; such 
as  sensation  of  heat  and  smarting  at  the  bottom  of  the  vagina, 
abundant  discharge,  acute  pain  during  coitus,  and  sometimes  during 
defecation,  weight  at  the  fundament,  dragging  in  the  groins  and 
loins,  flushings  of  heat  on  the  face,  attacks  of  hysteria,  etc.  The 
application  of  the  speculum  not  only  enables  us  to  discover  the  local 
lesions  we  have  enumerated,  but  also  a soft  swelling,  and  a state  of 
inflammatory  congestion,  marked  by  a deep  red  tint,  by  a sort  of 
ecchymosis,  and  finally,  by  extreme  sensibility  of  the  parts,  and 
oozing  of  blood  provoked  by  the  contact  of  the  exploring  instru- 
ment, by  the  operation  of  the  touch,  and  by  the  genital  act. 

The  treatment  of  granular  inflammation  of  the  cervix  requires,  like 
the  preceding  affections,  antiphlogistics,  small  revulsive  bleedings, 
narcotics,  derivatives,  absolute  repose  of  the  parts,  and  finally,  cau- 
terization with  the  acid -proto-nitrate  of  mercury.  Should  the  affec- 
tion, however,  occupy  the  whole  surface  of  the  os  tincae,  it  would  be 
proper  to  cauterize  only  a portion,  lest,  from  determining  too  great 
an  excitation,  serious  accidents  might  occur;  in  six  or  eight  days 
the  same  operation  should  be  repeated,  applying  the  caustic  only 
to  the  points  which  had  been  avoided  on  the  first  occasion. 

* Journal  Hebdomad,  de  Medecine,  tom.  vi.  p.  137. 


CHANCRE,  SCROFULOUS  ULCER,  ETC.,  OF  OS  TINCJE.  325 

If  the  disease  depended  on  syphilitic  or  scrofulous  taint,  etc.,  it 
should  be  treated  by  the  general  and  local  means  which  experience 
has  shown  most  useful  in  combating  these  different  diseases. 

OF  CHANCRES,  AND  SCROFULOUS  ULCERS,  ETC.,  UPON  THE  OS 

TINGLE. 

It  has  been  found,  in  a large  number  of  cases,  that  the  cervix  uteri 
may  be  the  seat  of  ulcers,  developed  primarily  or  consecutively, 
under  the  influence  of  a special  predisposition,  such,  for  instanse,  as 
the  venereal  virus,  or  some  scrofulous  or  herpetic  affection,  etc., 
whose  principal  characters  we  are  about  to  lay  down  in  a few 
words. 

The  chancrous  ulcer  of  the  os  tincm  depending  on  a syphilitic 
cause,  is  rounded,  its  bottom  is  of  a grayish  colour,  and  its  edges 
abrupt;  in  a word,  it  resembles  those  of  the  same  nature  developed 
on  the  glans  penis.  The  patients  feel  burning  and  aching  pains,  and 
know  not  what  position  to  assume  to  diminish  them.  There  flows  from 
the  orifice  of  the  vulva  a sero-mucous  fluid,  commonly  greenish,  and 
so  irritating  that  it  produces  an  inconvenient  and  often  painful  pruri- 
tus, and  even  erythema  of  the  parts  with  which  it  remains  in  con- 
tact. Moreover,  the  syphilitic  chancrous  ulceration  is  very  often 
characterized  by  other  primary  or  consecutive  symptoms  of  venereal 
infection,  such  as  blennorrhagia,  pustules,  vegetations,  and  chancres 
at  the  vulva,  etc.  Although  the  majority  of  practitioners  assert  the 
contrary,  it  is  less  rare  than  is  generally  supposed,  and  requires  a 
local  and  general  anti-syphilitic  treatment,  which  should  always  be 
preceded  by  the  use  of  baths,  injections,  and  demulcent  and  sedative 
lotions  and  applications. 

According  to  MM.  Cullerier,  Colineau  and  Jacquemin,  ulcerations 
of  this  kind  are  not  very  apt  to  degenerate  into  cancer ; what  would 
seem  to  militate  in  favour  of  the  opinion  of  these  distinguished  practi- 
tioners is  that  daily  observation  proves  that  prostitutes,  though  very 
liable  to  syphilitic  ulcerations  of  the  cervix  uteri,  do  not  furnish  more 
frequent  examples  of  cancer  of  the  womb  than  women  met  with  in 
ordinary  practice. 

There  are  certain  simple  chancrous  ulcers  consecutive  of  chronic 
metritis,  which,  though  presenting  nearly  the  appearance  as  those  of 
a syphilitic  nature,  not  only  do  not  yield  to  a methodical  mercurial 
treatment,  but  under  its  influence,  even  acquire  increased  severity. 
We  should,  in  this  case,  at  first  insist  chiefly  upon  the  employment 
of  antiphlogistics  and  narcotics,  recurring  afterwards  to  chlorureted 
injections,  to  astringents,  and  the  local  application  of  pledgets  of 
charpie  impregnated  with  the  same  solutions;  should  the  disease  resist 
these  remedies  administered  successively  or  simultaneously,  cauter- 
ization, with  acid  nitrate  of  mercury  would  become  a resource  that 
would  conclude  the  treatment.  We  add  that  non-specific  chan- 
crous ulcers  are  generally  more  serious  than  those  of  syphilitic  na- 
ture, and  that  when  developed  at  the  critical  age,  they  have  greater 


326  CHANCRE,  SCROFULOUS  ULCER,  ETC.,  OF  OS  TINC.3E. 

tendency  to  be  transformed  into  cancer  than  tho§e  observed  in  younger 
women. 

Scrofulous  ulcers  are  commonly  the  result  of  the  softening  of  the 
tubercles  of  the  cervix  uteri,  whose  characters  anterior  to  their  period 
of  softening  and  suppuration  we  have  pointed  out.  Ulcerations  of  this 
nature  are  always  preceded  by  the  escape  of  a caseous  matter  ana- 
logous to  that  which  is  furnished  by  suppurating  cervical  ganglions; 
the  discharge  of  this  matter  takes  place  through  a small  fistulous 
opening,  which  enlarges  little  by  little,  and  soon  exposes  to  view 
certain  fringed,  uneven  and  abrupt  edges,  circumscribing  a base  of 
a grayish  red  colour,  which  secretes  a sero-caseous  curdled  liquid, 
and  exhales  a disagreeable  odour,  not,  however,  like  that  of  cancer. 
Engorgement  of  the  cervix  and  even  of  the  body  of  the  uterus  often 
exists,  and  these  parts  may  likewise  be  the  seat  of  protuberances, 
easily  mistaken  for  the  result  of  carcinomatous  degeneration,  be- 
cause, excepting  the  lancinating  pains,  the  symptoms  are  nearly  the 
same.  To  avoid  all  error  on  this  point,  it  is  merely  necessary  to 
recollect  that  tubercles,  prior  to  suppuration,  always  present  a fluc- 
tuation, whilst  scirrhous  indurations  and  protuberances  are  always 
very  hard ; at  a later  period,  the  mistake  becomes  altogether  impos- 
sible, after  the  tubercles  have  opened  and  given  issue  to  the  casei- 
form  matter ; moreover,  the  facility  with  which  the  ulcer  deterges 
itself,  and  especially  the  rapidity  of  its  cicatrization,  will  suffice  to 
remove  every  doubt  that  may  remain  in  the  mind  of  the  observer. 

It  is  not  commonly  until  after  the  tubercles  have  been  converted 
into  ulcers,  that  we  suspect  their  existence ; for,  before  this  period, 
their  presence  does  not  appear  sensibly  to  modify  the  menstrual 
evacuations,  nor  determine,  consequently,  any  disorder  in  the  general 
functions  of  the  organism.  It  sometimes,  however,  happens  that 
tubercular  abscesses  pursue  a course  resembling  that  of  phlegmo- 
nous suppuration,  and  that  the  pain  resulting  from  them  attracts  the 
attention  of  the  physician ; the  finger,  in  this  case,  carried  into  the 
vagina,  perceives  the  fluctuation  of  the  tubercles,  which,  being  ex- 
posed to  view  by  the  speculum,  may  be  opened  by  a bistoury  plunged 
into  their  most  projecting  point.  Should  any  doubt  remain  as  to  the 
scrofulous  nature  of  the  ulcer,  the  constitution  of  the  female,  her 
mode  of  life,  and  especially  the  presence  of  old  cicatrices  and  engorged 
glands  in  the  neck,  would  greatly  assist  in  making  the  diagnosis  more 
clear. 

The  treatment  of  scrofulous  ulcers  should  at  first  be  directed  to- 
wards removing  the  inflammation,  if  any  exists;  watching  the  anti- 
phlogistics,  however,  especially  bleeding,  because  of  the  constitu- 
tion of  the  patient.  Recourse  should  then  be  had  to  astringent  in- 
jections and  to  cauterization,  the  efficacy  of  which  may  be  increased 
by  the  internal  use  of  bitters,  and  some  of  the  preparations  of  iodine, 
conjointly  with  all  the  hygieinic  and  dietetic  means  calculated  to 
modify  the  constitution. 

Before  passing  on  to  the  subject  of  cancerous  ulcers,  we  will  add 
that  there  are  sometimes  found,  upon  the  internal  surface  of  the  lips 


CARCINOMATOUS  ULCERS. 


327 


of  the  cervix  uteri,  phlyctamas  similar  to  those  so  often  observed 
upon  the  surface  of  the  buccal  mucous  membrane,  which,  by  opening, 
give  rise  to  small  ulcers. 

OF  CARCINOMATOUS  ULCERS. 

Carcinomatous  ulcers  differ  from  ulcerated  cancer  in  the  respect 
that,  like  noli  me  tangere  of  the  skin,  they  are  commonly  primary, 
or  at  least  succeed  to  simple  or  specific  ulcerations  that  are  neglected 
or  badly  treated,  and  which  we  have  already  treated  of ; whilst,  in 
cancer  properly  so  called,  the  ulceration  is  always  preceded  by  scir- 
rhous engorgement  of  the  subjacent  parts. 

When  the  disease  has  commenced  as  a carcinomatous  ulceration, 
the  base  of  which  consecutively  becomes  hard,  blood  flows  upon  the 
slightest  contact,  the  pains  are  superficial  and  slight,  the  patient  some- 
times feels  a sensation  of  gnawing,  which  she  cannot  define,  but 
which,  being  ordinarily  rather  agreeable  than  unpleasant,  excites  to 
coitus,  which  generally  occasions  acute  lancinating  pain.  The  ulcer, 
the  existence  of  which  may  be  ascertained  very  early  in  the  dis- 
ease, is  neither  accompanied  by  much  swelling  nor  by  deep  indu- 
ration ; its  surface  presents  a grayish  and  seemingly  inorganic  layer, 
which  is  continually  detached  and  renewed.  The  fluid  it  secretes  is 
very  viscid  and  readily  concretes  while  the  disease  is  stationary ; but 
as  soon  as  it  begins  to  progress  and  extend  to  the  neighbouring  parts, 
the  i ichorous  serosity  loses  in  viscidity  what  it  gains  in  quantity  and 
foetoir;  the  base  of  the  ulceration  hardens  more  and  more,  and,  soon 
assuming  -ah  the  characters  of  cancer,  properly  so  called,  produces 
the  same  exhaustion  of  the  organism,  and  leads  as  certainly  to  the 
death  of  the  patient. 

Primary  carcinomatous  ulcers,  though  they  produce  disorders  ana- 
logous to  those  of  ulcerated  scirrhus,  and  require  the  same  treatment, 
are  much  less  apt  to  relapse  when  we  once  succeed  in  removing  them. 
In  fact,  the  induration,  which  forms  the  base  of  carcinomatous  ulcers, 
is  accidental  and  consecutive,  and  even  seems  to  depend  on  the  exist- 
ence of  the  ulceration.  The  indurated  layer  on  which  they  repose  is 
sometimes  so  thin  that  it  is  difficult  to  distinguish  it  by  dissection, 
while  the  base  in  consecutive  ulcerated  cancer  is  always  primary 
and  of  considerable  depth,  which  explains  very  clearly  the  much 
greater  frequency  of  relapses  after  medical  treatment  or  an  operation. 

There  is  no  doubt,  in  our  mind,  that  the  pretended  cancers  whose 
cures,  by  means  of  injections  and  topical  remedies  of  different 
kinds,  have  been  proclaimed  to  the  public,  are  nothing  more  than 
primary  carcinomatous  ulcers,  and  not  true  ulcerated  scirrhous  tu- 
mours, having  all  the  characters  of  cancer,  properly  so  called. 
Though  we  believe  it  possible  to  obtain  the  resolution  of  a consecu- 
tive induration  of  small  extent,  by  the  modification,  and  especially  by 
the  destruction  of  the  primary  ulceration  which  has  provoked  its 
development,  we  regard  as  impossible  the  prompt  and  lasting  dis- 
persion of  an  ulcerated  scirrhus,  whatever  be  the  therapeutical 
agents  employed  for  its  cure. 


328 


CANCER  OF  THE  WOMB. 


It  is,  therefore,  of  the  utmost  importance  to  distinguish  a carcino- 
matous ulcer  from  ulcerated  cancer ; these  two  pathological  condi- 
tions are  the  more  easily  confounded,  as  they  both  present  an  ulcera- 
tion with  hardened  base ; the  former,  which  is  usually  the  largest  and 
of  the  least  depth,  reposes  on  an  indurated  base,  small  in  proportion 
to  its  extent,  and  which  is  always  thinner  than  that  of  ulcerated 
cancer.  To  make  a correct  diagnosis,  it  is  necessary,  therefore,  to 
recollect,  not  only  the  differential  signs  we  have  already  established, 
but  to  take  into  account,  likewise,  the  origin,  progress,  depth  and 
thickness  of  the  induration  on  which  this  kind  of  solution  of  conti- 
nuity rests.  We  dwell  no  longer  at  present  on  this  important  point, 
because  we  shall  have  to  revert  to  it  when  treating  of  the  diagnosis  of 
ulcerated  cancer. 

Carcinomatous  ulcers  require  the  therapeutical  remedies  that  we 
proposed  for  engorgements  and  simple  ulcerations ; that  is  to  say, 
antiphlogistics,  emollient  and  narcotic  injections,  revulsive  bleedings, 
derivatives,  etc.  If,  notwithstanding  the  careful  employment  of  these 
means,  the  symptoms  should  be  aggravated  and  threaten  to  destroy 
all  hope  of  cure,  we  must  resort  either  to  cauterization,  especially  if 
the  cervix  is  not  much  swollen,  and  if  the  ulceration  is  superficial,  or, 
lastly,  to  the  excision  of  the  diseased  part  by  means  of  a cutting  in- 
strument, which,  under  these  circumstances,  can  always  cut  beyond 
the  limits  of  the  disease.  It  is  in  this  condition,  more  than  any  other, 
that  the  operation  is  called  for,  and  promises  the  best  chance  of  suc- 
cess, because  the  ulceration,  which  has  been  developed  from  without 
inwards,  reposes  upon  a secondary  induration  of  no  great  depth. 

OF  CANCER  OF  THE  UTERUS. 

As  our  intention  is  less  to  concern  ourselves  with  what  relates  to 
pathological  anatomy  than  to  trace  a succinct  history  of  each  lesion 
in  a practical  point  of  view  especially,  it  will  be  readily  understood 
why  we  here  refrain  from  adverting  to  the  more  or  less  ingenious, 
or  more  or  less  absurd  opinions  which  both  ancient  and  modern 
authors  have  set  forth  upon  the  nature,  seat,  mode  of  development 
and  varieties  of  the  different  cancerous  affections.  As  medical 
science  remains  in  a state  of  doubt  and  uncertainty  on  this  subject, 
we  shall  retain  the  metaphysical  and  eminently  vicious  expression 
cancer,  to  indicate  in  a generic  manner  various  organic  alterations, 
whose  inherent  nature  is  unknown  to  us,  but  which,  though  of  varied 
form  and  appearance,  constitute  one  and  the  same  lesion,  and  have 
as  common  characters,  the  property  of  changing  and  disorganizing 
the  texture  of  the  uterus,  the  tendency  to  spread  superficially  and  in 
depth,  and  finally,  are  usually  beyond  the  resources  of  medicine  pro- 
perly so  called. 

The  cancerous  affections  of  the  womb,  as  just  defined,  present  dif- 
ferent modifications,  or  forms,  which  may  be  classed  in  the  following 
manner  : 

1.  Scirrho-cuncer , characterized  by  hard  engorgement,  and  al- 
teration of  the  shape  of  the  organ,  which  presents  protuberances, 


CANCER  OF  THE  WOMB. 


329 


some  of  them  indurated,  and  others  more  or  less  softened,  and  subse- 
quently ulcerated.  This  condition  is  accompanied  by  lancinating 
pains,  by  frequent  haemorrhages,  especially  if  the  disease  occupy 
only  a part  of  the  womb,  and  finally,  by  a leucorrhoeal  discharge, 
which  is  either  small  in  quantity  or  very  abundant.  This  altera- 
tion of  tissue,  which  may  vary  from  the  lardaceous  and  solaniform 
to  the  cartilaginous,  or,  in  certain  cases,  the  osseous  condition, 
produces  all  the  sympathetic  and  nervous  symptoms  and  pheno- 
mena which  depend  upon  the  circulation,  the  size,  and  change  of 
situation  of  the  organ,  as  is  the  case  in  simple  engorgements. 

What  particularly  distinguishes  the  cartilaginous  or  osseous  altera- 
tion, is  the  circumstance  of  the  organ  being  less  changed  in  shape 
than  in  the  scirrhous  or  tuberous  cancer,  and  that  we  do  not  have, 
as  in  the  latter  form,  acute  pains,  or  purulent  and  sanguine  dis- 
charges from  the  vulva.  It  is  likewise  less  dangerous,  and  some- 
times occasions  so  little  disturbance  to  the  economy,  that  women 
long  affected  with  it  have  been  known  to  live  to  a very  advanced 
age.  Let  us  add  that  the  cartilaginous  or  osseous  degeneration  of 
the  uterus  is  always  beyond  the  resources  of  art. 

2.  Ulcerated  cancer , which  is  the  last  stage  of  scirrhus,  is  recog- 
nized by  a solution  of  continuity,  with  hard  inverted  edges,  and  une- 
ven surface  of  a . grayish  colour.  The  discharge,  which  may  be 
simply  serous,  generally  consists  of  a sanious  acid,  horribly  fetid, 
sometimes  watery  and  slightly  sanguineous  matter,  which  escapes 
in  such  abundance,  that  it  soon  impregnates  the  frequently  renewed 
cloths  with  which  the  female  protects  herself.  The  ulcerated  sur- 
faces are  sometimes  covered  with  excrescences  and  vegetations, 
which  may  remain  for  a long  time  in  the  scirrhous  state,  but  which 
commonly  increase  with  great  rapidity,  and  form  soft,  fungous  tu- 
mours, bleeding  at  the  slightest  touch. 

This  form  of  cancer,  which  is  the  most  formidable  of  all,  and 
whose  progress  is  the  most  rapid,  is  accompanied  by  haemorrhages 
profuse  in  proportion  to  the  extent  of  the  disease  and  the  amount  of 
corrosion  of  the  vessels. 

3.  Fungous  cancer  is  that  form  which  appears  in  the  shape  of 
a mushroom-like  tumour  whose  pedicle  of  greater  or  less  size  is 
attached  to  the  circumference  of  the  os  tineas.  The  consistence  of 
the  tumour  is  soft  and  spongy,  its  surface  is  granular,  uneven,  and 
formed  of  a multitude  of  projecting  globules,  connected  like  the  gran- 
ules of  a raspberry  or  cauliflower ; its  colour,  which  is  violet,  livid 
or  reddish  brown,  approximates  to  that  of  the  placenta ; the  least 
pressure  upon  it  determines  a considerable  discharge  of  black  blood, 
an  almost  constant  exudation  of  which,  moreover,  is  mingled  with 
that  of  a reddish,  ichorous  serosity  of  most  disgusting  fetor.  In  this  con- 
dition it  is  easy  with  the  finger  to  detach  portions  of  soft,  brown  and 
very  friable  vegetations;  one  circumstance  we  may  note  here  is,  that 
women  generally  complain  to  the  last  physician  they  consult,  of  the 
brutality  of  the  first  who  attended  them,  and  who,  according  to  their 
statement,  made  the  examination  with  so  little  care,  as  to  cause 
abundant  bleeding. 


330 


CANCER  OP  THE  WOMB. 


The  fungous  cancer,  called  by  M.  Duparcque  mural  cancer,  pre- 
sents itself  sometimes  in  the  form  of  a non-pediculated  fungus,  having 
on  its  surface  a number  of  smooth  globules,  equal,  of  soft  consistence, 
vesiculous  appearance,  and  accumulated  in  masses  around  the  os 
tincse.  These  globular  granules,  which  resemble  gooseberries,  ( ribes 
uva  crisp  a,)  secrete  a serous  liquid,  which  is  so  abundant  at  times, 
as  to  pass  through  the  mattrasses  during  the  night,  and  compel  the 
patient  to  change  her  cloths  twenty  or  thirty  times  a day.  More- 
over, the  fluid  secreted  by  this  grape-like  fungus  is  almost  colour- 
less and  inodorous.  M.  Duges  has  published  several  cases  of  this 
second  variety  of  uterine  fungus  ; an  example  of  which  we  ourselves 
saw  in  1833,  in  the  wife  of  a water-carrier,  whom  we  advised  to 
enter  the  hospital  of  La  Pilie , in  M.  Lisfranc’s  wards,  where  she 
probably  died.  These  two  varieties  of  fungous  cancer,  and  espe- 
cially the  latter,  are  not  only  the  least  painful,  but  are  those  also 
which  offer  the  best  chance  of  cure. 

The  luematode  cancer  (bloody  cancer  of  M.  Duparcque),  hae- 
matoma  of  Hooper,  and  spongoid  inflammation  of  Burns,  although 
possessing  very  marked  differential  signs,  had  not  been  clearly  sepa- 
rated from  the  other  forms  of  cancer,  before  the  works  of  MM. 
Hooper,7*  Duparcque,!  and  Dugesf  appeared.  As  M.  Duparcque  is 
the  first  French  author  who  has  well  described  this  variety  of  can- 
cerous alteration,  we  shall  quote  its  principal  characters  from  that 
excellent  practitioner : “ We  recognize  this  form  of  cancer  by  the 
enlargement  of  the  uterus  without  deformity,  and  especially  of  its 
neck,  where  it  is  most  commonly  seated ; by  the  remarkable  soft- 
ness of  its  tissue,  by  the  sensation  of  crepitation  felt  in  touching  it ; by 
the  constant  discharge  of  black  and  grumous  blood,  mixed  with  clots, 
and  by  the  oozing  of  an  analogous  fluid,  coming  from  the  whole 
surface  of  the  tumour,  as  though  it  were  squeezed  like  a sponge. 
At  a very  advanced  period  of  the  disease,  there  are  mixed  with 
the  blood  certain  putrid  filaments,  and  fetid  matters  resulting  from 
the  detritus  and  decomposition  of  the  altered  tissue,  a decomposition 
which  generally  extends  from  the  centre  to  the  circumference,  like 
ramollissement,  or,  in  other  words,  which  commences  towards  the 
mouth,  and  extends  from  thence  both  to  the  neck  and  body  of  the 
womb.  This  produces  a seemingly  ulcerous  excavation,  and  the 
disease  then  assumes  the  form  of  ulcerated  cancer.”  We  add  that 
the  tumour  is  of  a brownish-red  colour,  and  its  surface,  which  ap- 
pears smooth  to  the  eye,  is  always  covered  with  lamina  of  clotted 
blood,  and  feels  slightly  uneven  when  touched.  It  is  probable, 
says  M.  Duparcque,  that  the  very  marked  sensation  of  crepitation 
which  is  felt,  depends  upon  the  displacement  of  the  serni-coagulated 
blood,  which  infiltrates  the  diseased  tissue. 

What  particularly  serves  to  distinguish  the  bloody  from  fun- 
gous cancer  is,  that  the  latter  is  supported  by  a pedicle  fixed  upon 
the  neck  of  the  uterus,  and  never  passing  beyond  it,  while  the  tumour 

* The  Morbid  Anatomy  of  the  Human  Uterus,  1832. 

f Traite  des  alterations  organ,  de  la  matrice,  p.  395. 

4 Traite  des  maladies  de  l’uterus,  tom.  ii.  p.  180. 


CANCER  OF  the  womb. 


331 


of  sanguine  cancer  is  without  any  pedicle,  spreads  to  the  body  of 
the  viscus  even,  and  has  a strong  tendency  to  extend  in  depth.  This 
distinction,  which  is  of  little  importance  in  the  medical  part  of  the 
treatment,  is  of  very  great  importance  for  the  surgical  treatment. 
Effectively  we  may  hope  much  from  the  excision  of  a fungous  can- 
cer, when  seated  upon  an  organ  whose  tissues,  perhaps,  are  healthy, 
while  the  same  operation  could  only  hasten  the  death  of  the  patient, 
or  even  immediately  determine  its  occurrence,  were  it  performed 
with  a view  of  destroying  a sanguine  cancer,  which  extends  more  or 
less  to  the  body  of  the  womb.  The  only  operation  that  ought  to  be 
attempted  in  such  a case  as  this  is  cauterization,  by  means  of  the 
actual  cautery,  as  we  have  seen  it  done  by  the  celebrated  Baron 
Larrey. 

5.  The  Encephaloid  or  Medullary  Cancer  is  characterized  by  a 
tumour  of  variable  size,  whose  external  surface  is  divided  into  more  or 
less  projecting  lobes,  containing  a cerebriform  substance  of  dull  white 
colour,  and  of  moderate  consistence  at  first,  but  afterwards  becoming 
pulpy  and  liquid,  like  thick  pap.  This  substance  may  exist  in  small 
encysted  masses,  or  in  small  lobes  which  are  not  encysted,  but  sepa- 
rated by  fissures,  less  deep  and  regular  than  those  of  the  encysted 
encephaloid  masses ; finally,  the  cerebriform  matter  may  be  contained 
in  masses  not  circumscribed,  but  it  is  infiltrated,  as  it  were,  in  the  tis- 
sue of  the  organ.  This  form  of  cancer,  which  often  exists  in  different 
parts  of  the  economy  at  the  same  time,  and  which  sometimes  follows 
tubercular  degeneration,  is  accompanied  by  a puriform,  ichorous,  and 
very  fetid  discharge,  bringing  along  with  it  softened  fragments  of  the 
uterine  tissue,  whose  separation  gives  rise  to  profuse  haemorrhages. 

The  various  pathological  degenerations,  just  described  by  us,  as 
so  many  forms  which  uterine  cancer  may  assume,  are  sometimes 
found  united,  wholly  or  partially,  in  the  same  uterus,  and  constitute 
in  that  case,  the  mixed  cancer , met  with  particularly  at  an  advanced 
period  of  this  frightful  disease. 

We  have  not  desired  to  make  different  species  of  the  varieties  and 
forms  which  we  have  just  described,  as  starting  from  the  same  point, 
but  merely  to  present  the  same  disease  under  all  its  different  aspects 
and  modifications,  without  destroying  that  pathological  unity  which 
it  ought  to  retain  in  theory  and  practice. 

The  causes  of  cancer  are  numerous  and  varied ; they  have  a more 
or  less  direct  action  upon  the  production  of  the  disease ; some  of  them 
are  general  or  predisposing,  others  determining  or  local. 

Amongst  the  predisposing  causes  are  hereditary  predisposition,  age, 
constitution,  and  mode  and  habits  of  life. 

Though  in  the  present  state  of  the  science  it  seems  difficult  to  ad- 
mit of  a cancerous  virus  transmissible  by  generation,  it  is  yekincon- 
testable  that  cancer  in  many  cases  appears  to  be  hereditary,  that  is  to 
say,  persons  born  of  parents  dying  of  a cancerous  affection  are  very 
much  disposed  to  contract  the  same  disease.  We  could  cite  many 
authentic  facts  in  support  of  this  opinion,  particularly  in  relation  to 
cancer  of  the  uterus,  which  is  more  disposed  than  any  other  organ 
to  carcinomatous  degenerations,  probably  from  the  nature  of  its  func- 


332 


CANCER  OF  THE  WOMB. 


tions,  from  its  close  and  compact  structure,  and  especially  the  great 
abundance  of  fibro-cellular*  tissue  with  which  it  is  supplied,  particu- 
larly about  the  cervix. 

Cancer  may  develop  itself  at  any  period  of  life,  but  it  is  very  rare 
for  that  of  the  uterus  to  make  its  appearance  earlier  than  at  twenty - 
five  years : nevertheless,  we  have  observed,  and  writers  have  reported 
several  examples  of  uterine  cancer  even  before  twenty  years  of  age. 
From  the  statistical  researches  we  have  been  enabled  to  make  in 
hospitals,  from  our  own  particular  practice,  and  especially  from  the 
works  published  upon  this  subject,  we  have  found,  by  following 
the  order  of  frequency,  that  this  frightful  malady  appears  most 
commonly  at  the  age  of  from  forty  to  forty-five  years,  then  from 
thirty  to  forty,  from  forty-five  to  fifty,  from  twenty-five  to  thirty, 
from  fifteen  to  twenty,  from  fifty  to  sixty,  and  finally,  from  sixty  to 
seventy.  It  may  be  seen  from  this  table  that  cancerous  affections  of 
the  uterus  are  the  more  frequent  in  proportion  as  that  organ  is  in  a 
greater  state  of  activity,  and  where  it  begins  to  pass  into  the  physio- 
logical inertia  of  the  critical  age. 

Badly  regulated  women  ; those  who  have  some  anomaly  of  the 
menstrual  function;  those  who  are  nervous,  irritable,  sensitive,  or  sub- 
ject to  the  more  vivid  emotions;  those  of  an  erotic  temperament,  and 
who,  constantly  tormented  by  venereal  desires,  give  themselves  up 
with  excess  to  masturbation  or  venery ; those  who  pass  their  lives 
in  crowded  parties,  and  the  tumult  of  fashionable  society  ; those  in 
whom  an  habitual  leucorrhcea,  cutaneous  eruptions,  neuralgic  or 
rheumatismal  pains  have  suddenly  ceased;  finally,  women  who  inha- 
bit large  cities,  and  particularly  those  who  have  borne  many  children, 
or  had  numerous  abortions,  or  frequent  attacks  of  metrorrhagia,  are 
more  subject  than  others  to  cancerous  affections  of  the  womb.  We 
should  also  range  amongst  the  predisposing  causes  to  these  lesions, 
celibacy,  sterility,  violent  grief,  frequent  paroxysms  of  anger,  and  all 
the  strong  passions  ; we  must  confess,  however  ; that  circumstances 
diametrically  opposed  do  not  prevent  the  development  of  the  disease, 
which  may  show  itself  under  the  influence  of  causes  inappreciable, 
but  inherent  in  the  constitution  of  some  persons. 

The  occasional  causes  of  uterine  cancer  are  all  those  whose  action 
may  give  rise  to  metritis.  Such  are  criminal  attempts  to  produce  abor- 
tion; the  presence  of  a foreign  body  in  the  vagina;  disproportion  be- 
tween the  genital  organs  of  married  people,  and  the  contusions  which 
may  result  from  this  cause ; venereal  enjoyments  before  puberty,  at 
the  epoch  of  the  physiological  revolution,  and  after  the  critical  age: 
the  presence  of  cellulo-vascular  polypi  upon  the  os  tincae  or  in  the 
interior  of  the  cervix  uteri ; and  finally,  all  causes  capable  of  produc- 
ing inflammatory  and  congestive  engorgements,  which  it  is  useless  to 
recapitulate. 

■*  Professor  Cruveilhier  has  proved,  by  a vast  number  of  interesting:  observations 
and  researches,  printed  in  the  Bibliotheque  Medicate,  that  the  fibro-cellular  tissue  is 
the  organic  element  chiefly  affected  in  cancer,  and  that  this  degeneration  seems  to 
have  a peculiar  predilection  for  those  organs  into  whose  composilion  a large  quan- 
tity of  this  tissue  enters.  Such  are  particularly  the  uterus,  the  mammae,  the  testicles, 
and  all  the  glands,  etc. 


CANCER  OF  THE  WOMB. 


333 


Whatever  may  be  the  origin  and  causes  of  cancerous  degeneration 
of  the  womb,  the  first  symptoms  of  the  disease  generally  escape  the 
attention  of  the  physician,  who  is  very  rarely  consulted  until  exten- 
sive disorder  already  exists  Moreover,  the  derangements  which 
women  experience  at  the  beginning  are  so  slight,  that  they  them- 
selves pay  no  attention  to  them,  and  it  may  happen  also  that  the 
disease  shall  attain  a very  advanced  stage  without  any  precursory 
symptom  to  cause  its  presence  to  be  suspected.  There  are,  in  fact, 
young,  fresh  and  brilliant  women,  appearing  to  have  all  the  attributes 
of  perfect  health,  in  whom  cancer  has  taken  deep  root,  and  in  whom 
the  uterus  is  reduced  to  the  state  of  a putrid  slough  presenting  a mere 
fetid  cloaca.  We  have  seen  cases  of  this  kind,  and  several  modern 
authors,  among  others  MM.  Lisfranc,  Recamier,  Pauly,  Tealier,  etc., 
have  published  examples  of  them. 

In  general,  the  first  symptoms  that  make  their  appearance,  are 
derangements  of  the  menstruation;  augmentation;  diminution  or  tran- 
sient suppression  of  the  menstruse;  their  frequent  and  irregular  return; 
a leucorrhoeal  discharge  mixed  with  sanguineous  stria?,  and  having  a 
redder  tint  after  coitus ; sensation  of  pressure  on  the  anus,  and  weight 
in  the  hypogastrium,  dragging  in  the  loins  and  lumbar  regions,  a 
sort  of  vesical  tenesmus  and  painful  sensation  during  the  expulsion 
of  the  urine  and  during  defecation.  Some  women  experience  a sort 
of  voluptuous  pruritus  in  the  genital  parts,  especially  at  the  vulva, 
which  inclines  them  to  coitus  and  illicit  manoeuvres ; the  conjugal 
act  generally,  but  not  always,  causes  more  or  less  acute  pain ; to 
these  symptoms  are  added  acute  and  transient  pains  in  different  parts 
of  the  body,  especially  in  the  breasts,  which  become  firmer  and 
larger ; the  patients  experience  alterations  of  tension  and  retraction 
of  the  abdominal  walls  ; attacks  of  hysteria  ; unusual  melancholy  ; 
extreme  disgust  for  food  ; strange  longing,  and  finally,  a general  un- 
easiness which  cannot  be  accounted  for,  until  all  doubts  are  removed 
as  to  the  existence  of  the  disease. 

When  such  phenomena  as  these  make  their  appearance,  and  espe- 
cially when  they  last  beyond  the  period  of  transient  irritations,  it  is 
of  the  greatest  importance  to  examine  the  sexual  organs  to  convince 
ourselves  as  to  the  nature  of  the  evil ; the  least  delay  would  expose 
the  patient  to  irremediable  danger,  and  might  compromise  the  honour 
of  our  art  and  the  reputation  of  the  physician. 

In  the  first  stage  of  the  disease,  the  os  tincse  is  found,  upon  exa- 
mination, hard,  tumefied,  warm,  painful  and  sometimes  softened, 
and  uneven  at  different  points ; the  posterior  lip  is  always  more 
projecting  and  more  voluminous  than  the  anterior ; the  mouth  of  the 
uterus  is  partially  open  and  irregular ; the  finger,  especially  its  ex- 
tremity, when  withdrawn  from  the  vagina,  is  commonly  covered 
with  bloody  mucus,  like  that  provoked  by  copulation.  It  is  often 
difficult  to  distinguish  commencing  cancer  from  subacute  metritis 
with  simple  induration ; when  of  scirrhous  nature,  however,  the 
neck  of  the  uterus  is  less  regular  in  its  form,  generally  softer,  less  sen- 
sible and  larger  than  usual.  The  engorgement  is  then  more  cir- 


334 


CANCER  OP  THE  WOMB. 


cumscribed,  and  rarely  extends  to  the  body  of  the  organ,  as  in  simple 
engorgements. 

Instead  of  following  a progressive  course,  it  sometimes  happens 
that  cancer  in  the  first  stage  remains  stationary,  until  some  inap- 
preciable cause,  by  communicating  to  it  a new  impulse,  hastens  its 
progress.  The  first  doubts  as  to  the  diagnosis  soon  cease  altogether. 
The  disease  makes  rapid  progress,  and  new  symptoms  make  their 
appearance.  The  pain  becomes  pungent,  the  losses  of  blood  more 
frequent,  and  the  vaginal  discharges  more  abundant.  The  Touch 
at  this  second  period,  in  connection  with  the  exploration  by  the 
speculum,  shows  the  uterus  to  have  acquired  the  weight  and  dimen- 
sions which  it  possesses  at  the  second  month  of  pregnancy.  The 
orifice  of  the  neck  resembles  a hard,  knobbed  and  uneven  ring, 
more  or  less  red,  and  covered  with  a sanguineous  mucous  fluid,  or 
is  even  bathed  in  pure  blood.  If  the  entire  organ  be  implicated,  the 
rectal  and  hypogastric  examination  commonly  enables  us  to  distin- 
guish the  extent  of  the  tumour  and  the  rounded  inequalities  which 
project  more  and  more  from  its  surface.  When  the  degeneration  is 
encephaloid,  we  see  the  cancerous  diathesis  promptly  manifested  by 
softening  and  ulceration  of  the  tumour,  and  by  the  rapid  growth  of 
the  disease  in  extent  and  depth.  The  pains  which  are  then  almost 
constant  are  often  dull  and  gnawing,  but  always  accompanied  by 
acute  shootings,  which  the  patients  compare  to  a flash  of  fire,  or  to 
the  pricking  of  a needle  or  a penknife.  Generally,  they  concentrate 
upon  the  uterus  whence  they  extend  to  the  ligaments  of  the  organ. 
The  body  of  the  uterus,  which  becomes  more  and  more  hyperiro- 
phied  in  consequence  of  the  extension  of  the  disease,  causes  com- 
pression of  the  vessels  and  nerves  of  the  pelvis,  and  then  becomes 
one  of  the  chief  causes  of  the  deep-seated  lancinating  pains  which 
are  felt  in  the  hips,  thighs  and  loins,  in  the  direction  of  the  sciatic 
nerve  and  its  branches.  Sometimes  the  pains  seem  no  longer  to 
arise  in  the  pelvis,  but  extending  in  various  directions,  they  become 
so  acute  in  the  different  articulations  of  the  inferior  extremities,  as  to 
simulate  rheumatism  more  or  less  accurately.  The  functions  of  the 
neighbouring  organs  become  impaired  ; the  constipation  is  obstinate, 
the  desire  to  urinate  continual,  and  finally  the  uterine  haemorrhages 
augment  in  frequency  and  often  become  permanent,  when  the  scir- 
rhous tumour  has  ulcerated,  or  when  fungosities,  vegetations,  and 
especially  true  fungous  haematodes  have  been  developed  on  the  cervix. 

In  the  third  stage,  the  primary  cancerous  ulceration,  or  that  pre- 
ceded by  scirrhous  engorgement,  is  bounded  by  edges  which  are 
indurated,  torn,  bleeding,  and  unequally  inverted  on  the  exterior 
circumference  of  the  cervix  uteri.  The  bottom  of  this  orifice  is  soon 
found  changed  into  a kind  of  putrid  slough,  which  the  finger  rea- 
dily penetrates,  and  whence  flows  a characteristic  ichorous  and  san- 
guineous matter,  that  corrodes  the  thighs,  is  of  disgusting  odour, 
and  so  horribly  fetid  as  to  persist  a long  time  after  the  touch,  in  spite 
of  repeated  washings  with  soap  or  chlorinated  water.  From  the  bot- 
tom and  whole  surface  of  the  ulceration,  bleeding  granulations  and 
ftjngous  vegetations,  of  which  we  have  already  spoken,  often  arise. 


CANCER  OF  THE  WOMB. 


335 


As  the  disease  now  makes  rapid  progress,  the  walls  of  the  cervix 
may  soon  be  eaten  away,  and  reduced  to  the  state  of  a slough ; the 
disorganization  often  extends  to  the  body  of  the  organ,  which  is  some- 
times perforated,  so  as  to  establish  a communication  with  the  perito- 
neal cavity  ; it  may,  also,  in  some  cases,  be  propagated  to  the  neigh- 
bouring organs,  the  bladder,  for  instance,  the  rectum,  the  vagina  ; 
and  even  the  exterior  parts  of  generation  have  been  known  to  be 
included  in  this  focus  of  destruction,  and  to  form  a hideous  cloaca 
where  the  urine  and  the  faecal  matter  mingle  with  the  cancerous 
rpatter;  sometimes  portions  of  softened  flesh,  and  clots  of  black  and 
putrified  blood  detach  themselves  from  the  cancerous  fungosities, 
whence  also  flow  ichorous,  sanguineous  and  blackish  matters,  or 
matter  resembling  wine  lees.  Then  come  on  haemorrhages  whose 
abundance  so  rapidly  exhausts  the  forces,  and  often  cause  the 
death  of  the  patient  some  months  before  the  period  when  it  would 
have  taken  place,  without  this  accident.  When  the  suffering  is 
slight,  women  retain  a certain  degree  of  embonpoint  and  freshness, 
but  generally  the  pains  are  so  agonizing  as  to  render  life  insupport- 
able, and  their  exaggeration  may  cause  death  in  a few  days,  as  MM. 
Bayle,  and  Cayol,*  Tealier,t  and  other  authors  have  stated,  with 
cases  in  point. 

Beside  these  local  symptoms,  we  must  mention  the  phenomena  of 
cachexia  or  general  alteration  of  the  organism  which  constitute  the 
most  unfortunate  effect  and  last  stage  of  the  cancerous  diathesis. 

When  women  reach  this  frightful  period  of  the  disease,  they  pre- 
sent the  most  heart-rending  picture  of  human  misery ; in  fact,  the 
functions  of  assimilation  are  exhausted ; appetite  is  gone,  digestion 
is  deranged  in  a thousand  ways;  emaciation,  more  or  less  rapid, 
sometimes  passes  into  marasmus ; the  osseous  system  participating  in 
the  disease,  becomes  friable,  fragile  and  breaks  of  itself,  as  it  were. 
The  skin,  which  is  dry,  swollen,  wrinkled,  and  adherent  to  the  bones, 
assumes  the  dull  white  colour  of  wax,  or  the  yellow  straw  colour 
which  characterizes  cancerous  affections;  the  attitude  has  a peculiar 
character  in  this  pathological  condition ; the  sad  and  drooping 
expression  bears  the  impress  of  suffering  and  depression ; the  eyes 
sunken  in  their  orbits,  the  livid  and  singularly  contracted  lips,  the 
fuliginous  teeth,  the  drawn,  hippocratic  face,  furrowed  with  deep 
wrinkles,  give  to  the  patient  the  aspect  of  a corpse  : finally,  colliqua- 
tive diarrhoea,  symptomatic  of  intestinal  ulcerations,  vomiting,  oedema 
of  the  inferior  extremities,  dropsy,  hectic  fever,  insomnia,  intolerable 
sufferings,  profuse  haemorrhages,  despair  and  death  come  to  com- 
plete this  sad  and  afflicting  scene. 

The  progress  of  cancer  varies  according  to  its  kind  and  the  epoch 
at  which  has  been  developed  the  organic  modification  which  predis- 
poses to  scirrhous  and  encephaloid  degeneration,  fundamental  altera- 
tions for  the  greater  number  of  cancerous  affections.  If  the  disease 
begin  with  the  scirrhous  state,  it  may  remain  indolent  and  stationary 
for  a long  time,  and  softening  of  the  tumours  may  occur,  with  great 
slowness,  so  that  sometimes  females  are  not  prevented  from  reaching 


* Dictionnaire  des  Sciences  Med.,  art.  Cancer. 
-j-  Du  cancer  de  la  Matrice,  p.  Ill,  1836. 


336 


CANCER  OF  THE  WOMB. 


very  advanced  old  age.  Rapid  ulceration  of  cancer  produces  the 
most  serious  disorders  in  a short  time,  and  a few  months  may  suffice 
to  bring  it  to  its  last  stage  ; nevertheless,  this  unhappy  termination 
has  been  known  not  to  occur  until  after  several  years  ; it  is  probable 
that  the  difference  depends  on  the  multiplicity  and  intensity  of  the 
predisposing  causes,  as,  for  example,  the  temperament  of  the  patients, 
their  sensibility,  and  particularly  the  kind  of  treatment.  Death  often 
occurs,  either  after  a terrific  haemorrhage  or  after  sanguine  losses  in 
small  quantity  but  too  frequently  repeated,  after  peritonitis,  violent 
convulsions,  pneumonia,  or  other  affections,  which  are  frequent  com- 
plications of  uterine  cancer.  We -should  add,  that  the  disease  gene- 
rally makes  more  rapid  progress  in  proportion  as  the  female  is 
younger,  and  that  though  in  some  cases  ulceration  seems  to  stay  its 
progress,  and  afford  some  consolation  to  the  patient  and  hope  to  the 
physician  ; this  happy  change,  which  is  always  ephemeral,  does 
not  long  justify  the  advantages  which  had  been  thought  to  be  de- 
rived from  the  therapeutical  means  put  in  practice.  The  patient,  who 
had  been  relieved  at  first  by  a palliative  treatment,  is  soon  discou- 
raged ; she  changes  her  physician,  essays  the  strongest  remedies,  and 
in  her  despair  applies  to  old  women,  to  charlatans,  to  magnetizers,  to 
homoeopaths,  who  in  turn  promise  her  a speedy  and  radical  cure, 
but  who  only  hasten  on  the  fatal  event. 

While  the  diagnosis  of  cancer  of  the  womb  is  not  generally  ob- 
scure in  the  latter  periods  of  the  disease,  all  authors  agree  in  the 
opinion,  that  it  is  quite  otherwise  in  the  beginning.  Effectively,  in 
chronic  metritis  with  simple  induration,  the  cervix  uteri,  as  in  scir- 
rhous engorgement,  is  larger  and  harder  than  in  the  normal  state ; 
the  surface  of  the  tumour  may  be  at  first  smooth  and  polished  in  both 
cases,  and  finally  the  pain  may  be  wanting,  it  may  be  slight,  or  even 
lancinating,  in  cases  of  simple  induration  as  in  those  of  scirrhous  in- 
duration, or  commencing  cancer.  M.  Lisfratic,  whose  experience  is 
very  great,  and  whose  opinions  are  of  so  much  importance  in  this 
matter,  published  in  the  Gazette  Medicate,  the  following  differential 
signs. 

1.  Simple  engorgement  is  softer,  and  its  surface  is  more  *even  to 
the  touch  than  scirrhus,  which  presents  prominences  and  inequali- 
ties. 

2.  In  scirrhus,  the  mucous  membrane  of  the  neck  is  of  a dull 
white  colour,  which,  according  to  this  celebrated  practitioner,  is  not 
the  case  in  simple  engorgement. 

3.  Scirrhus  is  developed  more  slowly  ; for  example,  when  an  en- 
gorgement dates  from  one  or  two  months  only,  and  especially  when 
it  follows  abortion,  ordinary  labour,  or  sudden  suppression  of  the  men- 
struge,  we  infer,  says  M.  Lisfranc,  that  it  is  not  of  a scirrhous  nature. 

4.  Finally,  simple  engorgement  requires  a treatment  of  a month 
or  six  weeks,  whilst  scirrhus  is  much  longer  in  recovering.  We 
will  add  to  the  characters  of  scirrhus  mentioned  by  the  able  surgeon 
of  La  Piti&,  that  engorgement  is  generally  less  sensible,  less  active, 
and  more  circumscribed  than  simple  induration  ; we  shall  also  add, 
that  its  formation  is  not  accompanied  by  such  marked  symptoms,  nor 


CANCER  OF  THE  WOMB. 


337 


does  it  produce  at  the  outset  such  troublesome  symptoms  or  such 
well-marked  general  phenomena.  Finally,  let  us  say  that,  under  the 
influence  of  bleeding,  strict  diet,  repose,  antiphlogistics  and  resolvents, 
simple  engorgement  of  the  uterus  usually  diminishes  with  great 
rapidity,  which  never  occurs  in  scirrhous  degeneration,  even  at  the 
beginning. 

When  induration  of  the  cervix  does  not  present  the  characteristic 
signs  of  scirrhus  in  a marked  degree,  we  should  infer  the  absence 
of  this  alteration,  and  act  as  though  we  had  positively  ascertained  a 
simple  hard  engorgement,  that  is  to  say,  we  should  resort  with  me- 
thod and  perseverance  to  the  various  therapeutical  means  of  which 
we  spoke  under  the  head  of  chronic  metritis  and  induration. 

We  shall  be  able  to  distinguish  scirrhus  from  polypus  of  the  uterus 
if  we  reflect  that  the  latter  tumours  are  altogether  insensible,  that 
they  are  isolated  from  the  os  uteri  and  present  a smooth  surface,  a 
peculiar  elasticity,  and  an  oval,  regular  and  pediculated  shape,  while 
scirrhous  indurations  are  adherent,  uneven,  irregular,  more  or  less 
sensible,  hard  to  the  touch,  and  of  almost  stony  consistence.  Fibrous 
tumours,  developed  in  the  thickness  of  the  walls  of  the  cervix  uteri, 
are  also  recognized  by  their  firmness,  insensibility,  and  considerable 
size ; and  by  their  rounded  and  not  lobular  form.  It  should  never 
be  forgotten,  moreover,  that  the  cervix  uteri  is  susceptible  of  consi- 
derable elongation,  which  we  have  spoken  of  before ; that  the  os 
tincse,  which  varies  considerably  as  to  size  in  the  normal  state,  is  in 
some  women  hypertrophied  without  being  diseased  at  all;  and, 
lastly,  that  labour  often  causes  protuberances  and  fissures  of  its  tissue 
which  are  easily  distinguished  from  cancerous  tumours. 

As  we  gave,  under  the  head  of  carcinomatous  ulcers,  their  differen- 
tial diagnosis,  we  deem  it  unnecessary  to  revert  to  this  subject,  and 
we  shall  also  pass  by  in  silence,  the  characteristic  symptoms  of  dif- 
ferent lesions,  among  others  the  cellulo-vascular  polypus,  which  we 
described  in  another  part  of  the  work,  and  pointed  out  as  having 
some  symptoms  analogous  to  those  of  cancer  of  the  cervix  uteri. 

The  prognosis  of  uterine  cancer  is  always  unfavourable;  for  it  is 
the  peci\Jiar  property  of  this  disease  to  disorganize  and  destroy,  more 
or  less  rapidly,  not  only  the  part  in  which  it  is  seated,  but  likewise, 
step  by  step,  those  which  lie  near  it.  Nevertheless,  when  the  os 
tincce  alone  is  implicated,  especially  if  the  cancer  be  the  result  of  a 
degenerated  primary  ulcer,  the  prognosis  is  less  unfavourable,  and 
the  disease  offers  some  chance  of  cure ; we  ought,  on  the  contrary, 
no  matter  what  be  its  origin,  form  and  mode,  of  development,  to 
regard  it  as  almost  certainly  fatal,  when  it  passes  beyond  the  cervix 
uteri  and  extends  to  the  body  of  the  organ.  It  is,  therefore,  of  the 
utmost  importance  to  attack  cancer  at  its  very  commencement,  and 
never  to  lose  sight  of  the  excellent  advice  given  by  Doctor  Miller,* 
when  he  said : “ any  prolonged  derangement  of  the  genital  organs  of 
the  female  or  of  their  functions ; any  inconvenience  which  exists ; 
any  suffering,  even  slight,  which  is  repeated,  should  arouse  the  atten- 

* Memoirs  de  l’Acad.  de  Med.,  tom.  ii.,  p.  333.  1832. 

22 


338 


TREATMENT  OF  CANCER  OF  THE  WOMB. 


tion  of  the  physician  and  demand  examination ; unfortunately,  women 
rarely  demand  the  assistance  of  medicine,  at  the  first  appearance  of 
the  symptoms,  or  rather  they  refuse  to  submit  themselves  to  any  kind 
of  exploration  ! they  trust  to  nature  the  care  of  their  cure ; but,  vain 
hope  ! they  are  ever  deceived  in. their  expectations. 

TREATMENT  OF  CANCER  OF  THE  WOMB. 

All  the  efforts  of  the  physician  should  have  as  their  object  not 
merely  to  arrest  the  first  steps  of  the  disease  and  crush  it  at  its  origin, 
but  also  to  prevent  its  return  by  the  most  attentive  care,  and  by 
removing  all  causes  which  tend  to  reproduce  or  keep  it  up.  There 
is  no  doubt  that  the  primary  source  of  cancer  of  the  womb  is  chro- 
nic inflammation  of  that  organ.  To  cure  this  affection,  and  thus 
dispel  the  irritation  which  maintains  the  engorgement,  is  most  com- 
monly to  prevent  uterine  cancer,  and  consequently  save  the  women 
from  the  most  frightful  of  diseases.  As  we  have  already  dilated  at 
length  upon  the  treatment  of  chronic  metritis,  and  the  different 
engorgements  which  it  may  occasion,  we  deem  it  unnecessary  to 
revert  to  this  subject  here. 

The  basis  for  the  treatment  of  a commencing  cancer,  is  just  the 
same  as  that  for  primary  engorgements  of  the  uterus,  or  for  the 
ulcerations  which  may  be  their  cause  or  effect.  Thus,  to  diminish 
the  pain  and  arrest  the  progress  of  the  disease,  we  should  have  re- 
course to  revulsive  bleedings,  to  exutories,  and  to  a soothing  regi- 
men ; we  should  prescribe  a milk  diet,  white  meats,  repose,  baths, 
emollient  narcotic  and  astringent  injections,  enemata  and  poultices  of 
the  same  nature,  and  the  other  different  therapeutical  agents  which 
we  have  already  mentioned. 

The  diet.  We  should  commence  by  depriving  the  patient  of  one- 
fourth  of  her  ordinary  aliment,  then  of  a third,  and  finally  of  the  half, 
if  her  constitution  permits ; for  there  are  some  women  who  support 
rigid  diet  with  the  greatest  difficulty.  The  dishes  that  ought  to  be 
allowed  are  white  meats,  fish,  herbaceous  and  vegetable  substances, 
feculent  substances  prepared  with  much  dilution,  preparations  of 
milk,  and  cooked  fruits  or  very  ripe  un-cooked  fruits.  Spirituous  and 
aromatic  drinks  must  be  positively  forbidden;  water,  slightly  reddened 
with  wine,  may  be  allowed  during  the  repasts,  but  at  other  times  the 
use  of  emollient  drinks  must  be  continued.  We  add  that  the  diminu- 
tion of  the  aliment  or  the  cura  famts  is  one  of  the  most  important 
elements  in  the  treatment  of  cancer. 

Bleeding  should  be  employed  when  the  female  is  young  and 
plethoric,  when  the  pulse  is  full,  and  especially  when  there  exists  a 
fluxionary  movement  towards  the  uterus.  Bleeding  from  the  arm 
acts  not  only  by  diminishing  the  mass  of  the  blood,  but  also  by 
creating  a revulsion,  which  carries  the  blood  towards  the  supra-dia- 
phragmatic  regions.  It  should  amount,  generally,  to  half  a palette,* 
a palette  and  a half,  or  two  palettes  at  most,  according  to  the  strength 

* A palette  contains  four  ounces. — Tram. 


TREATMENT  OF  CANCER  OF  THE  WOMB. 


339 


and  constitution  of  the  patient.  It  ought  never  to  be  employed 
except  about  eight  days  before  or  after  the  epoch  of  the  menstruae, 
and  should  be  repeated  less  frequently  when  the  disease  is  already 
of  long  standing.  The  methodical  use  of  general  bleeding,  the  ad- 
vantages of  which  in  . the  treatment  of  cancerous  affections  and  in- 
flammations of  the  uterus  are  incontestable,  dates  from  the  era  of 
Hippocrates:  this  principle,  which  has  become  a fundamental  one  in 
medical  science,  and  which  was  followed  also  by  Galen,  Pare,  Val- 
salva, Morgagni,  Heister,  Ledron,  Fearon,  and  Hufeland,  is  justly 
recommended  by  all  modem  authors,  and  particularly  by  M.  Lisfranc. 

After  the  revulsive  or  depletory  general  bleedings,  conjointly  with 
other  antiphlogistic  remedies,  have  dissipated  the  inflammatory  symp- 
toms and  the  local  pain,  several  practitioners,  among  others  M.  Du- 
parcque,  Miller  and  Teallier,  recommend  applications  of  leeches  to 
the  os  tincse,  which  is  exposed  by  means  of  the  speculum  of  M.  Re- 
camier.  The  latter  plan,  which  we  have  seen  employed  with  advan- 
tage on  several  occasions  in  simple  engorgement  with  or  without 
induration  of  the  neck,  should  be  applied  in  the  following  manner: 
when  the  womb  is  in  a state  of  procidentia,  it  is  sufficient  to  separate 
the  labia  majora  in  order  to  expose  the  os  tincse  : if  the  uterus,  on 
the  contrary,  is  situated  more  deeply,  the  cylindrical  speculum  must 
be  used ; from  six  to  fifteen  leeches  must  be  introduced  through  it 
up  to  the  cervix,  and  retained  upon  it  either  with  a plug  of  linen,  or 
with  a sort  of  hollow  central  piece  six  or  eight  lines  in  depth.  With 
this  instrument,  which  is  lined  with  a piece  of  transparent  gauze,  and 
fastened  at  the  bottom  by  a shank  with  a handle  bent  at  an  obtuse 
angle,  we  can  readily  keep  the  leeches  in  their  places,  while  they  are 
prevented  from  moving  about  and  attaching  themselves  elsewhere 
than  on  the  neck,  from  being  unable  to  create  a vacuum  on  the  tissue 
of  the  gauze,  which  makes  it  impossible  for  them  to  fasten  them- 
selves upon  it,  as  they  often  do  in  the  parietes  of  the  speculum.  To 
render  their  application  still  more  convenient,  we  should  be  careful 
to  remove  with  a small  sponge  or  fine  pencil  of  charpie,  the  mucus 
upon  the  surface  of  the  neck,  and  then  wash  them  away  by  means 
of  repeated  injections.  Ten  or  fifteen  minutes  suffice  to  fill  the 
leeches,  which  are  then  to  be  removed,  as  they  fall  off,  by  forceps. 
The  discharge  of  blood  ought  to  be  encouraged  by  warm  injections, 
which  at  the  same  time  remove  the  clots  of  blood.  If  the  haemor- 
rhage prove  too  abundant,  it  may  be  arrested  by  plugging  the 
vagina. 

Without  entirely  rejecting  the  application  of  leeches  to  the  cervix 
uteri,  we  believe  with  M.  Lisfranc,  that  it  often  has  the  inconveni- 
ence of  increasing  the  congestion  of  the  organ,  and  we  think  it  should 
never  be  resorted  to  after  induration  of  the  neck  has  assumed  the 
scirrhous  character,  because,  in  this  condition,  as  we  have  several 
times  seen  happen,  each  puncture  may  be  converted  into  so  many 
cancerous  ulcerations.  We  also  regard  as  almost  always  hurtful  in 
the  treatment  of  cancer,  leeches  applied  to  the  anus,  the  vulva,  groins, 
and  around  the  pelvis;  for,  excepting  in  some  particular  cases,  they 
augment  the  congestion  of  the  uterus,  and  all  the  disorders  dependent 


340 


TREATMENT  OF  CANCER  OF  THE  WOMB. 


upon  if.  Simple  and  emollient  general  baths,  heated  as  moderately 
as  possible,  yet  prepared  in  such  a way  that  the  patient  shall  not  feel 
chilled,  are  an  excellent  means  for  diminishing  the  nervous  erythism 
and  pain  which  accompany  affections  of  the  uterus ; the  duration  of 
the  bath  should  be  at  least  one  hour,  and  at.  most  six  hours,  and  they 
may  be  renewed  every  day,  or  every  two  days,  according  to  the 
strength,  habits  and  constitution  of  the  patient.  The  heat  of  the  water 
should  be  maintained  at  an  equal  temperature  ; we  must  be  careful 
not  to  prescribe  this  excellent  therapeutical  means  for  women  in 
whom  it  produces  oppression,  uneasiness,  or  different  nervous  symp- 
toms. 

Hip-baths  ought  to  be  forbidden,  as  they  always  determine  uterine 
congestion,  and,  as  a consequence,  more  or  less  acute  pains. 

The  injections  must  be  emollient  sometimes,  at  others  narcotic  or 
discutient,  according  to  the  indications ; they  should  be  at  a tempe- 
rature of  fifteen  or  twenty  degrees  of  Reaumur,  and  are  used  not 
only  with  the  view  of  cleansing  the  cancerous  ulcers,  but  also  of  con- 
tributing to  the  resolution  of  the  scirrhous  indurations  of  the  neck  of 
the  uterus.  As  they  sometimes  act  like  true  douches,  it  is  necessary 
to  moderate  their  discutient  and  often  too  exciting  action,  by  throw- 
ing the  liquid  with  more  or  less  force,  according  to  the  effect  we  seek 
and  the  results  we  may  already  have  obtained  from  their  employ- 
ment. These  injections,  which  are  especially  useful  in  chronic  and 
indolent  indurations,  ought  to  be  made  with  a syringe,  having  a 
curved  gum-elastic  canula,  previously  oiled. 

Irrigations  or  prolonged  injections,  as  well  as  douches,  are  still 
more  powerful  means  for  effecting  the  resolution  of  hard  and  indo- 
lent engorgements.  They  are  simple  or  medicated,  according  to  the 
nature  of  the  liquid,  the  temperature  of  which  ought  to  be  nearly  cold. 
The  former  are  composed  of  infusions  of  aromatic  plants,  or  of  saline 
or  sulphurous  solutions,  according  to  the  indications.  We  prepared  in 
the  year  1828,  a very  simple  apparatus  for  administering  continuous 
irrigations  or  douches.  The  apparatus  consists  of  a kind  of  trestle 
with  three  legs,  three  meters  high,  in  the  middle  of  which  is  sus- 
pended a wooden  pail  communicating  with  a flexible  tube  terminated 
by  a gum-elastic  tube  introduced  into  the  vulva.  The  force  of  the 
jet  is  in  proportion  to  the  elevation  of  the  vase  and  the  quantity 
of  fluid  allowed  to  escape.  When  we  desire  to  use  irrigations  and 
not  the  douche,  the  force  of  impulsion  of  the  water  is  lessened  by 
means  of  a small  sponge  placed  at  the  extremity  of  the  canula  in- 
troduced into  the  vulva.  The  liquid  with  which  the  sponge  is  im- 
pregnated then  flows  drop  by  drop  into  the  vagina,  whence  it  escapes 
to  fall  into  a tin  basin,  placed  under  the  hips  of  the  patient,  at  the 
centre  of  an  opening  formed  in  the  mattrass.  A second  flexible  tube 
is  adapted  to  the  hollow  handle  of  the  basin  which  is  in  the  bed, 
and  conveys  the  fluid  as  it  is  received  into  another  vessel  placed 
on  the  floor.  We  can  in  this  way,  and  without  wetting  the  woman, 
administer  irrigations  for  as  long  a time  as  we  desire ; when  we 
think  proper  to  arrest  the  flow  of  the  liquid,  the  apparatus  is  with- 
drawn, and  the  opening  in  the  mattrass  filled  up  by  the  separated 


TREATMENT  OF  CANCER  OF  THE  WOMB. 


341 


portion  of  this  last,  which  fits  perfectly.  In  cases  of  vaginal  fistula, 
with  incontinence  of  urine,  a mattrass  and  basin  disposed  as  we  have 
just  described,  present  advantages  which  it  is  useless  to  dwell  upon. 
M.  Charriere,  a distinguished  manufacturer  of  surgical  instruments, 
has  invented  a sort  of  pump-syringe,  which  shows  great  ingenuity, 
and  may  serve  to  administer  douches  and  irrigations;  but  it  obliges 
the  patient  or  some  other  person  to  work  the  piston  during  the  time 
that  the  fluid  is  running. 

Compression , which  that  able  practitioner,  M.  Recamier,  has  pro- 
posed as  a method  of  treatment  for  cancerous  tumours,  is  a means 
which,  although  very  useful  in  a number  of  other  cases,  particularly 
in  indurated  tumours  of  the  breast,  does  not  seem  to  offer  the  same 
advantages  in  scirrhous  indurations  of  the  uterus,  either  because  of 
the  situation  of  the  organ,  which  renders  its  employment  difficult,  or 
because  of  the  inflammation  and  pain  which  it  almost  always  causes 
in  the  vagina,  bladder  and  uterus.  It  is  always  necessary,  therefore, 
to  refrain  from  its  use  unless  the  tumour  is  entirely  indolent,  and  if  it 
be  the  seat  of  the  least  irritation.  The  mode  in  which  it  is  used  is 
simply  to  employ  a cup  and  ball  pessary,  in  which  the  cervix  uteri 
lodges  itself,  and  is  compressed  by  the  weight  of  the  organ,  and  that 
of  the  abdominal  viscera. 

Absolute  repose  and  a dorsal  decubitus  are  the  more  useful,  be- 
cause, without  them,  all  other  means  are  nearly  powerless.  We 
should  request  the  patient,  therefore,  to  confine  herself  to  bed,  which 
ought  to  be  hard  and  made  of  hair  mattrasses.  But,  as  rest  in  bed 
has  the  inconvenience  of  producing  congestions  of  the  pelvis,  and 
even  excitement  of  the  genital  organs,  it  is  necessary,  agreeably 
to  the  advice  of  M.  Lisfranc,  to  recommend,  during  the  day,  either  a 
pallet  or  a mattrass,  thrown  upon  the  floor  or  on  a table. 

Narcotics  are  likewise  administered  for  the  purpose  of  diminishing 
the  pain  and  stimulus  which  give  rise  to  the  uterine  congestion.  They 
are  prescribed  in  the  form  of  injections  made  of  decoctions  of  poppy- 
heads,  of  morel,  of  hyoscyamus,  of  cicuta,  of  potato-tops,  etc.,  in 
small  enemata,  with  addition  of  from  eight  to  fifteen  drops  of  lauda- 
num ; and  internally,  in  the  form  of  pills  or  antispasmodic  draughts. 
We  may  add  to  these  remedies,  the  internal  use  of  resolvents,  such  as 
tincture  of  iodine,  from  which  M.  Hahnemann  says  he  derived  great 
benefit  in  a case  of  cancer  of  the  uterus,  which  had  reached  a high 
degree  of  intensity ; lime-water,  administered  by  M.  Kempel,*  in  the 
dose  of  from  one  to  three  ounces,  in  a cup  of  milk ; ergot,  which  has 
an  altogether  special  action  upon  the  uterus,!  the  extract  of  cicuta, J 

* Revue  Medicale  ; aout  1825. 

f Ergot  advantageously  employed,  in  the  pillular  form,  in  the  dose  of  from  two  to 
ten  grains  daily,  in  cases  of  haemorrhagic  engorgement,  has  likewise  been  used  with 
great  success,  in  cases  of  engorgement  of  the  os  tincae  with  ulcerations,  first  by  Doc- 
tor Pauly,  then  by  M.  Malgaigne,  Vigny,  and  by  ourself,  who,  like  those  practition- 
ers, have  prescribed  it  several  times  in  combination  with  gummy  extract  of  opium,  in 
very  small  doses,  the  sixth  or  quarter  of  a grain  in  each  pill.  M.  Lesuerre,  pharmaceut- 
ist, at  No.  71  Rue  de  la  Harpe,  prepares,  under  the  direction  of  Doctor  Pauly,  a syrup 
of  this  substance,  one  tablespoonful  of  which  contains  two  grains  and  a half  of  ergot, 
and  one-twelfth  of  a grain  of  extract  of  opium.  The  ordinary  dose  of  syrup  is  two 
spoonfuls  per  diem. 

f The  extract  of  cicuta,  whose  marvellous  effects  have  been  recounted  by  Storck, 


342 


TREATMENT  OF  CANCER  OF  THE  WOMB. 


and  the  cherry-laurel  water,  employed  by  MM.  Osiander  and  Carron 
du  Villards.  Finally,  it  might  be  useful  to  employ,  at  the  same  time, 
revellents,  as  sulphurous  douches,  like  the  stream  from  a watering- 
pot,  and  derivatives',  such  as  cauteries,  moxas  and  blisters  applied  to 
the  sacrum,  groins,  loins  and  internal  surface  of  the  thighs.  External 
resolvents  are  likewise  recommended,  amongst  others,  frictions  to  the 
regions  just  indicated,  and  especially  to  the  hypogaster,  with  mercu- 
rial ointment,  or  with  the  ointment  of  hydriodate  of  potash,  which 
have  also  been  used  with  advantage  in  cancerous  ulcers,  by  Doctor 
IJlmann,  of  Marburg;*  and  finally,  frictions  beneath  the  tongue  and 
to  the  internal  surface  of  the  labia  majora,  with  the  oxide  of  gold, 
from  which  M.  Chretient asserts  that  he  has  obtained  wonderful  effects. 

If  all  these  means  combined,  fail  to  arrest  the  disease,  or  prevent 
the  softening  and  ulceration  of  the  cancer,  or  the  extension  of  a pri- 
mitive carcinoma,  the  disease  is  incurable  by  medicine,  properly  so 
called,  alone,  and  henceforth  the  mission  of  the  physician  consists  less 
in  attempting  to  cure  the  disease  than  in  trying  to  arrest  its  progress, 
to  alleviate  suffering  and  prolong  life.  The  only  means  which  re- 
main must  be  drawn  from  surgery,  and  consist  of  cauterization,  and 
of  the  partial  or  total  ablation  of  the  organ. 

To  fulfil  his  duty  properly  the  physician  should  employ,  not  only 
all  the  resources  which  may  be  at  his  disposal,  but  he  should  endea- 
vour also  to  console  and  encourage  his  patient,  to  raise  her  hopes, 
and  decide  her  as  soon  as  possible  to  submit  to  the  operations  which 
he  may  deem  necessary,  and  which  offer  some  chance  of  success. 

The  medical  treatment  will  now  be  merely  palliative  and  sympto- 
matic. We  should  resort,  at  this  period,  to  narcotic  injections,  made 
with  decoctions  of  morel  or  hyoscyamus,  in  union  with  some  emol- 
lient liquid.  We  may  resort,  also,  to  injections  of  cherry  laurel,  to 
continuous  irrigations  simply  emollient,  or  mixed  with  the  decoctions 
of  the  plants  we  have  just  mentioned,  to  prolonged  baths,  to  ene- 
mata,  and  to  vaginal  poultices  made  of  the  pulp  of  the  pumpkin,  or 
of  grated  or  boiled  carrots,  and  rendered  narcotic  by  concentrated 
decoctions  of  poppy-heads,  of  belladonna  leaves,  of  morel,  of  cicuta, 
etc.f  Fomentations  of  the  same  nature,  frictions  to  the  hypogas- 
trium  with  Rousseau’s  laudanum,  or  with  the  oil  of  hyoscyamus, 
may  likewise  be  employed. 

and  the  efficacy  of  which,  in  the  treatment  of  cancer,  M.  Recaraier  speaks  of  having 
often  witnessed,  has  always  appeared  to  us  to  have  but  little  effect,  and  to  produce ,no 
advantageous  result.  We  have  found,  on  the  contrary,  that  cicuta  commonly  de- 
ranges the  digestive  functions,  and  determines  more  or  less  severe  headaches.  MM. 
Marjolin,  Duges,  Pauly,  and  some  other  physicians  have  remarked  the  same  thing. 
This  may  possibly  depend  on  the  faulty  mode  in  which  the  extract  of  cicuta  is  pre- 
pared by  most  pharmaceutists. 

* Gazette  de  Sanle,  Sept.  5th,  1823,  and  May  25th,  1824.  Doctor  Ulmann  has  like- 
wise employed  the  hydriodate  of  potash  by  injection. 

j-  De  la  methode  Jatraleptique,  p.  318. 

t To  employ  the  vaginal  poultices,  and  prevent  their  solid  materials  from  escaping 
and  collecting  in  the  vagina,  we  observe  the  precaution  of  retaining  them  in  that 
cavity  by  means  of  a small  gauze  bag,  the  tissue  of  which  is  sufficiently  close.  In 
this  way  they  are  introduced  and  withdrawn  with  the  greatest  facility.  The  bag  is 
first  introduced  into  the  vagina  with  the  nozzle  of  the  syringe,  which  serves  to  inject 
the  liquid  poultice. 


TREATMENT  OF  CANCER  OF  THE  WOMB. 


343 


The  insomnia  should  be  treated  by  the  internal  use  of  gummy 
extract  of  opium,  in  doses  of  half  a grain,  gradually  increased  to 
four  grains.  The  small  enemata  of  water  or  milk,  as  advised  by 
Morgagni,*  with  addition  of  a grain  of  gummy  extract  of  opium, 
or  several  drops  of  laudanum,  generally  procure  great  relief.  Blis- 
ters sprinkled  with  one  or  two  grains  of  muriate  of  morphia,  and 
applied  to  the  lumbar  region  and  internal  part  of  the  thighs,  are 
commonly  very  useful,  and  have  not  the  disadvantage  of  constipa- 
ting the  patient.  The  same  is  true  as  to  the  suppositories  of  beurre  de 
cacao , which  we  prescribe  every  evening,  and  direct  to  be  made  of 
a drachm  of  cocoa  and  a quarter  of  a grain  or  a grain  of  acetate  of 
morphia.  We  might  likewise,  in  order  to  calm  the  pain,  add  to  each 
injection  five  or  six  drops  of  phosphoric  acid  ; we  should  mention, 
however,  that  the  plan  recommended  by  M.  Alibert,!  has  failed  in 
our  hands. 

The  infectious  odour  exhaled  from  carcinomatous  ulcers,  which 
fatigues  the  patients  as  much  as  the  persons  who  attend  them,  may 
be  partly  neutralized  by  means  of  chloruretted  injections  and  lotions, 
and  also  by  soot-water  and  the  solution  of  creosote  injected  into  the 
vagina.  These  different  means  have  not  the  advantage  merely  of 
destroying  the  disgusting  odour  of  the  discharge,  but  of  calming  the 
violence  of  the  pain,  of  diminishing  the  quantity  of  the  secretions, 
and  even  of  staying  the  progress  of  the  disease. 

To  moderate  the  profuse  serous  discharges  and  haemorrhages 
which  rapidly  weaken  the  patient,  we  should  resort  to  the  internal 
employment  of  some  astringents,  such,  for  example,  as  the  water  of 
Robel,  (a  mixture  of  sulphuric  acid  one  part,  and  alcohol  three  parts,) 
in  the  dose  of  half  a drachm  or  a drachm  in  a draught ; to  extract 
and  tisan  of  rhatany,  and  to  lemonade  made  with  citric  acid  and 
with  syrup  of  quinces  or  comfrey.  We  may  also  employ,  in  some 
cases,  but  with  more  care,  cold  astringent  injections,  made  with  de- 
coctions of  oak  bark,  of  bistort,  of  Goulard’s  lotion,  or  with  very 
weak  solutions  of  sulphate  of  alum  or  of  zinc,  etc.  We  ought  to 
mention  that,  though  the  astringent  injections  often  arrest  the  bleed- 
ings, they  have  the  serious  inconvenience  of  irritating  the  ulcerations 
and  hastening  their  progress. 

The  plugging  of  the  vagina  is  a means  which,  in  this  case,  may  be 
very  useful,  but  it  always  causes  acute  pain,  unless,  as  M.  Lisfranc 
recommends,  we  observe  the  precaution  of  plugging  the  inferior 
portion  only;  finally,  small  revulsive  bleedings  and  applications  of 
cups  and  leeches  under  the  breasts  are  remedies  which  it  is  well  not 
to  reject. 

The  constipation  determined  by  the  internal  use  of  narcotics,  may 
be  opposed  by  mild  laxatives,  especially  by  decoctions  of  tamarinds 
and  prunes,  by  enemata  of  honey,  with  addition  of  a tablespoonful  of 
olive  oil,  and  finally,  by  suppositories  of  beurre  de  cacao,  used  morn- 
ing and  evening.  If  vomiting  supervene,  we  should  prescribe  Selt- 
zer water,  Riverius’s  draught,  and  sub-nitrate  of  bismuth,  etc. ; 
finally,  we  must  relieve  retention  of  urine  by  means  of  catheterism. 

+ De  Sedib.  et  caus.  morb.,  epist.  47,  art.  25,  1660. 

4 Elements  de  Th6rapeutique. 


344 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  WOMB. 


Such  are  nearly  all  the  means  which,  in  these  disastrous  cases,  pre- 
sent themselves  to  the  physician  for  relieving  the  sufferings  and  pro- 
longing the  lives  of  his  patients. 

SURGICAL  TREATMENT  OF  CANCER. 

When  the  cancerous  affection  is  well  marked,  when  there  remains 
some  doubt  even  as  to  its  true  nature,  if  the  disease  has  advanced  in 
spite  of  the  methodical  employment  of  the  therapeutical  resources 
we  have  described,  we  ought  to  resort,  as  early  as  possible,  to  the 
means  offered  us  by  surgery,  that  is  to  say,  to  cauterization  or  to  the 
excision  of  the  affected  part. 

The  cauterization  of  simple  or  cancerous  ulcerations  of  the  cervix 
uteri,  was  first  brought  into  repute  in  France,  by  M.  Recamier,  and 
after  him,  by  Dupuytren,  M.  Lisfranc,  and  several  other  practitioners. 
This  energetic  and  often  efficacious  means  is  useful,  not  only  in  chang- 
ing the  mode  of  vitality  and  the  sensibility  of  simple  ulcers  which 
resist  ordinary  treatment,  but  also  in  destroying  fungous  vegetations 
and  cancerous  or  carcinomatous  ulcerations,  having  but  little  depth 
or  surface.  As  a general  rule,  we  should  defer  its  employment  as 
long  as  there  exists  acute  inflammation,  or  considerable  tumefaction 
of  the  cervix.  It  is  necessary  to  reject  it  altogether,  even  when  we 
are  uncertain  of  reaching  the  limits  of  the  disease.  It  is  equally 
contra-indicated,  during  the  four  or  five  days  which  precede  the 
menstrua?,  during  their  presence,  and  for  three  or  four  days  after 
their  cessation. 

Though  Baron  Larrey  seems  to  have  employed  the  iron  heated  to 
redness*  with  advantage,  the  powerful  caustics  are  generally  pre- 
ferred, such  as  solid  nitrate  of  silver,  caustic  potash,  arsenical  paste, 
chloride  of  antimony,  the  sulphuric  and  nitric  acids,  concentrated 
nitro-muriatic  acid  holding  in  solution  sixteen  grains  of  chloride  of 
gold  or  platinum  to  the  ounce, t the  chloride  of  zinc,f  creosote, § which 

* M.  Larrey  applies  the  actual  cautery  by  exposing  the  parts  by  means  of  an  ivory 
speculum,  because  the  metallic  speculums  being  good  conductors  of  caloric,  are 
rapidly  warmed  by  the  hot  iron  and  produce  too  much  heat  in  the  walls  of  the  vagina; 
a speculum  of  wood,  of  bone  or  of  glass,  would  answer  as  well  as  that  of  M.  Larrey, 
and  has  the  advantage  of  being  cheaper. 

f This  caustic,  which  was  proposed  by  M.  Recamier,  and  which  we  have  seen  em- 
ployed by  that  able  and  ingenious  practitioner,  has  not  fulfilled  the  anticipations 
which  it  gave  rise  to  at  first. 

i Doctor  Cancoin  has  extolled  the  chloride  of  zinc,  as  possessing  the  advantage  of 
giving  less  pain  and  producing  a dry  slough.  This  practitioner,  with  two,  three,  or 
four  parts  of  flour,  forms  a soft  paste,  the  thickness  of  which  ought  to  be  in  propor- 
tion to  the  depth  of  the  part  to  be  destroyed.  For  superficial  cauterization,  M.  Can- 
coin  uses  a mixture  composed  of  eight  parts  of  nitric  acid  to  one  of  chloride  of  zinc. 

§ We  communicated  to  the  Academy  of  Sciences  in  1834,  a case  of  cure  of  sanious 
ulceration  of  the  neck  of  the  womb,  which  had  resisted  every  other  means,  even  the 
cauterization  with  the  acid  nitrate  of  mercury,  but  which  soon  cicatrized  after  several 
cauterizations  with  a mixture  of  ninety  parts  of  distilled  water  to  one  of  creosote. 
This  case  has  since  been  reported  in  an  excellent  memoir,  by  Doctor  Miguet, 
published  at  Taris,  in  1834,  the  title  of  which  is:  Recherr.hes  Chimigues  et  Mtdicales 
sur  la  Creosote , in  8v.,  observ.  iii.  p.  70.  Notwithstanding  this  favourable  result,  we 
have  been  forced  to  limit  the  employment  of  the  new  substance  which  was  discovered 
by  Reichenback,  because  its  application  is  often  very  painful.  Our  brother  practi- 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  WOMB. 


345 


cleanses  the  ulcers  and  hastens  cicatrization;  and  finally,  the  acid 
nitrate  of  mercury,  which  is  most  frequently  employed,  because  it  is 
more  active  and  easier  of  application  than  any  of  the  caustics. 

For  cauterization,  the  patient  must  be  placed  across  the  bed,  as  for 
the  application  of  the  speculum.  This  instrument  should  be  intro- 
duced and  placed  in  such  a way  that  its  mouth  may  embrace  the 
cervix  uteri,  and  protect  the  walls  of  the  vagina  from  the  contact  and 
spreading  of  the  caustic.  When  the  os  tincse  is  fully  exposed,  we 
remove  the  mucus  from  its  surface  with  a piece  of  linen,  a sponge 
or  a pledget  of  charpie,  fixed  upon  a little  stick  of  wood,  in  a pair 
of  dressing-forceps,  in  our  caustic-holder,  or  in  a forceps  attached 
to  the  handle  of  our  small  lever  for  redressing  the  cervix.  We 
then  finish  the  cleansing  of  the  parts  with  one  or  two  injections 
of  cold  water,  the  jet  of  which  should  be  directed  upon  the  sides  of 
the  speculum,  and  not  into  the  cervix ; then,  having  dipped  a little 
pencil  of  charpie,  or  the  sponge  of  our  caustic-holder,  into  the  acid 
proto-nitrate  of  mercury,  prepared  with  two  drachms  of  this  salt  to 
an  ounce  of  nitric  acid,  we  touch  the  ulcerated  surfaces  the  more 
lightly  in  proportion  as  they  are  more  superficial,  and  as  we  approach 
nearer  to  the  edges  of  the  diseased  parts. 

The  caustic  should  be  left  at  least  a minute  in  contact  with 
ulcerations  of  a cancerous  nature,  and,  in  this  case,  it  is  useful  to  re- 
peat the  cauterization  several  times  in  succession.  For  this  purpose, 
we  should  observe  the  precaution  to  wet  the  pencil  each  time,  and 
pass  it  lightly  against  the  edge  of  the  vessel  which  holds  the  acid,  in 
order  that  it  may  be  charged  only  with  the  quantity  strictly  neces- 
sary for  acting  upon  the  ulcerated  surfaces.  We  prevent,  by  this 
means,  the  action  of  the  caustic  upon  the  neighbouring  parts  from 
producing  inflammation  and  adhesion  of  the  walls  of  the  vagina,  and 
the  various  accidents  described  by  MM.  Marjolin,  Lisfranc,  Duges, 
Pauly,  Loir,  and  other  practitioners. 

When  the  operation  is  terminated,  we  should  immediately  make 
use  of  an  injection  of  cold  water,  or  of  some  emollient  or  narcotic 
decoction,  which  ought  to  be  left  during  several  minutes  at  the  bot- 
tom of  the  speculum,  so  as  to  bathe  the  os  tincae  and  diminish  the 
pain,  which,  however,  is  not  generally  severe.  If  the  first  cauteriza- 
tion be  not  sufficient,  it  must  be  repeated  after  the  fall  of  the  slough, 
which  takes  place  on  the  fifth  or  sixth  day,  and  the  same  means 
should  be  renewed  until  we  have  completely  destroyed  the  altered 
portions,  which  is  known  to  be  the  case  when  the  ulcerated  surface 
presents  granulations  like  those  developed  in  simple  wounds.  In 
general,  cauterization  should  not  be  used  except  for  ulcerations  of 
slight  depth  and  extent  of  surface,  or  in  order  to  destroy  fungus 
resting  on  healthy  tissues : in  this  last  case,  we  ought,  before  ap- 
plying the  caustic,  to  excise  the  vegetations  with  the  curved  scis- 
sors which  we  invented  for  this  purpose,  and  satisfy  ourselves  before 

tioner,  Doctor  Teallier  who,  since  the  publication  of  our  case  has  likewise  made 
use  of  the  creosote,  seems  to  have  renounced  it  for  the  same  reason.  That  able  prac- 
titioner employed  this  extremely  active  remedy  in  the  proportion  of  ten  drops  to  a 
tablespoonful  of  water. — ( Du  Cancer  de  la  Matrice , p.  244, 1836.) 


346 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  WOMB. 


operating,  that  the  surrounding  tissues  are  not  the  seat  of  an  acute 
inflammation.  If  such  were  the  case,  we  should  first  employ  baths, 
enemata,  emollient  injections  and  poultices,  and  we  should  treat  the 
consecutive  inflammation  by  the  same  means,  and  by  general  and 
local  bleedings. 

We  shall  conclude  what  we  had  to  say  upon  cauterization,  by 
adding  that,  though  it  is  often  efficacious  in  cases  of  superficial  ulcera- 
tion, it  is  always  useless,  and  even  injurious,  in  extensive  ulcerations 
and  deep  scirrhous  degenerations.  The  resection  of  the  diseased 
parts  is  then  the  only  resource  which  offers  any  chance  of  success. 

AMPUTATION  OF  THE  NECK  OF  THE  UTERUS. 

The  resection  of  the  neck  of  the  uterus  above  its  connection  with 
the  vagina,  though  a triumph  of  modem  surgery,  had  already  been 
recommended  by  the  ancients.  Ambrose  Pare*  advises  the  section 
of  the  thym  of  the  neck  of  the  womb,  which  is  ‘‘hard,  rough  or 
uneven,  of  a livid  colour,  fungous,  with  a pricking  pain,  like  points 
of  needles.”  In  speaking  of  malignant  thym , he  says,  “ that  it  be- 
comes angry  at  being  touched,  and  throws  out  a large  quantity  of 
blood  when  cut  or  irritated,  especially  after  commerce  with  men,  or 
when  the  woman  has  walked  or  taken  violent  exercise.”  He  adds, 
“ that  we  may  apply  the  speculum  matricis,  in  order  to  see  more 
easily  . . . .”  Lapeyronie,  being  consulted  for  a sarcoma  attached 
to  the  margin  of  the  uterus,  which  was  callous  at  that  point,  thinking 
that  the  tumour  might  be  extirpated  with  the  callosity  from  which  it 
grew,  cut  into  the  healthy  part,  and  the  patient  recovered  perfectly. 
N.  Tulpius,  who  died  in  1674,  assertst  that  scirrhous  tumours  of  the 
uterus,  which  had  already  acquired  the  malignity  of  cancer,  have  been 
successfully  extirpated.  Judging,  however,  from  the  drawing  he  gives 
of  one,  which  was  removed  from  a woman  named  Gertruda  Turina,  it 
would  seem  that  these  tumours  were  in  fact  mere  polypi.  According 
to  Baudelocque,  the  resection  of  the  cervix  uteri  was  proposed  by 
Lauvariol,  in  1780;  it  was  also  advised  by  Wrisberg,f  in  17S7;  by 
Monteggia,  in  1788,  in  a work§  translated  into  German  by  Dr.  Schless- 
ing,  and  commented  upon  by  Dr.  Kravel,  in  a dissertation  published 
at  Jena  in  1786,  where  he  renews  the  proposition  of  the  celebrated 
surgeon  of  Milan;  and  finally,  in  1801,  Professor  Osiander  pub- 
lished the  first  well-authenticated  case  of  resection  of  cancerous  os 
tincae.  Having  published,  seven  years  later,  in  the  Bulletin  of  the 
Royal  Society  of  Gottingen,  a memoir  in  which  he  described  the 
results  of  several  operations  of  the  same  kind,  his  successful  attempts 
produced  so  great  a sensation  in  Germany,  that  the  Josephine  Aca- 
demy of  Vienna  proposed  a reward  of  two  hundred  florins  for  the 
best  essay  upon  this  subject. 

This  new  and  bold  operation  made  a great  noise  in  France,  and 

* CEuvres  d’Ambroise  Pare,  lib.  xxiv.  p.  1012. 
f Observat.  Medend.,  lib.  iii.  cap.  34.  avec  fig.  1641. 
t De  Uteri  Resectione,  etc.  Goetingue,  1787. 

(j  Annotazionni  pratiche  sopra  gli  mali.  ven.,  p.  179. 


AMPUTATION  OF  THE  NECK  OF  THE  WOMB. 


347 


was  adopted  and  several  times  performed  by  Dupuytren  and  Pro- 
fessor Recamier,  to  whom  the  science  is  indebted  for  the  cylindrical 
speculum.  But  the  hopes  which  the  first  results  gave  rise  to,  not 
being  realized,  it  was  in  some  sort  abandoned  by  the  surgeons  who 
had  been  its  first  partisans,  when,  in  1826,  the  numerous  cases  pub- 
lished by  M.  Lisfranc,  forced  the  most  incredulous  to  recognize  the 
little  immediate  danger  usually  incurred,  and  to  acknowledge  that 
when  practised  in  good  time,  and  in  the  proper  mode,  it  forms  the 
only  resource  which  affords  any  chance  of  success  in  cases  rebellious 
to  all  other  means. 

Several  methods  have  been  proposed  or  employed  for  performing 
the  resection  of  the  cervix  uteri,  either  by  bringing  the  organ  down 
to  a level  with  the  vulva,  or  by  operating  without  displacing  it. 

M.  Osiander,  having  carried  two  curved  needles,  armed  with  liga- 
tures, up  to  the  cervix  uteri,  and  pierced  it  in  two  opposite  points  of 
its  circumference,  drew  the  organ  as  near  as  possible  to  the  vulva  by 
making  gentle  traction ; he  then  divided  the  diseased  parts  with  Pott’s 
bistoury,  and  afterwards  plugged  the  vagina  with  masses  of  charpie 
on  a small  sponge,  covered  with  a mixture  of  powdered  alum,  gum- 
arabic  and  resin. 

Professor  Dupuytren,  and  in  his  manner,  most  surgeons,  have  sub- 
stituted for  the  ligatures  of  Osiander  a very  long  Muzeux  forceps,* 
with  slightly  curved  hooks,  to  seize  or  loosen  at  will  the  cervix  uteri ; 
we  shall  detail  in  a few  words  the  method  of  M.  Dupuytren,  as  it  is 
described  in  the  Medecine  Op&ratoire  of  Sabatier.  “ The  surgeon 
introduces  the  speculum,  properly  oiled,  into  the  vagina,  and  gives  it 
to  an  assistant  to  hold.  This  done,  he  seizes  and  draws  gently  to- 
wards him,  with  a Muzeux  forceps,  held  in  the  left  hand,  all  the  por- 
tion of  the  cervix  uteri  affected  with  carcinomatous  degeneration,  and 
removes,  with  a double-edged  knife,  curved  laterally,  or  what  is  better, 
with  very  long  and  strong  scissors,  also  curved  laterally,  and  exceed- 
ingly sharp,  which  should  be  held  in  the  right  hand,  and  carried 
alternately  above,  below,  and  on  the  sides,  turning  the  concavity  in- 
wardsNand  causing  them  to  act  as  much  as  possible  on  the  parts 
situated  beyond  the  limits  of  the  disease.” 

The  method  of  M.  Lisfranc,  which  is  the  one  most  generally  followed, 
also  consists  in  drawing  down  the  womb  to  a level  with  the  vulva  ; 
the  apparatus  and  instruments  necessary  for  the  operation,  are  a bi- 
valve speculum,  two  of  Muzeux’s  forceps,  two  probe-pointed  bis- 
touries, one  straight  and  another  with  the  blade  curved  on  the  edge, 
strong  scissors,  curved  on  the  flat,  a pair  of  forceps  for  torsion,  liga- 
tures, compresses,  charpie,  and  finally,  a T bandage. 

In  order  that  nothing  may  be  omitted,  and  the  better  to  describe 
the  method  in  all  its  details,  we  shall  give  it  here,  as  we  described 
it  in  our  memoir  on  amputation  of  the  neck  of  the  uterus,  from  the 

* So  called  after  the  surgeon  who  invented  them.  They  resemble,  in  general 
arrangement,  the  ordinary  dressing-forceps  of  the  pocket-case,  but  differ  in  having 
the  blades  to  terminate  in  small  hooks,  which  lock  when  the  instrument  is  shut,  and 
in  being  more  or  less  curved. — Trans. 


348 


AMPUTATION  OF  THE  NECK  OF  THE  WOMB. 


thesis  of  Doctor  Avenel,  of  Rouen,  formerly  pupil  and  prosector  of 
the  course  on  operative  medicine  given  by  M.  Lisfranc. 

The  woman  being  placed  in  bed,  as  directed  for  our  method,  M. 
Lisfranc  employs  a speculum,  composed  of  two  half  cylinders  of  tin, 
to  the  extremities  of  which  are  soldered  two  pieces  of  iron,  which 
articulate  with  each  other.  From  this  arrangement  it  follows  that 
by  pressing  on  the  .free  extremities  of  these  pieces  of  iron,  the  two 
cylinders  separate  from  each  other ; their  separation  allows  the  very 
large  neck  to  be  received  between  them  more  easily,  and  gives  room 
for  the  passage  of  the  instruments  necessary  for  the  operation.  Be- 
sides, by  stretching  the  vagina  through  its  whole  extent,  it  prevents 
that  canal  from  covering  the  neck  more  or  less,  by  forming  a fold  at 
its  bottom;  The  forceps  of  Muzeiix,  employed  by  M.  Lisfranc,  are 
longer  and  stronger  than  those  generally  used  ; their  hooks,  which 
are  less  curved,  hold  the  organ  very  well,  without  our  being  obliged 
tOf  separate  them  to  a great  extent;  their  length,  moreover,  helps 
to  keep  the  hand  of  the  assistant  who  holds  them,  out  of  the  way. 
The  operator,  having  ascertained  the  position  of  the  cervix,  in  order 
that  he  may  find  it  as  soon  as  possible,  and  with  the  greater  ease, 
introduces  the  speculum. 

The  os  tincoe  is  cleansed,  if  necessary,  in  order  to  be  sure  of  its 
presence,  and  of  its  not  being  covered  by  any  fold  of  the  vagina. 
The  forceps,  closed,  are  carried  directly  beneath  the  organ  ; as  soon 
as  the  blades  are  sufficiently  open,  and  engaged  between  the  cervix 
and  sides  of  the  speculum,  to  seize,  if  possible,  two  points  directly 
opposed  to  each  other,  the  operator  presses  lightly  upon  them  in  pro- 
portion as  he  buries  them  in  the  tissue  of  the  womb. 

This  manoeuvre  is  indispensable  in  order  to  follow  the  upward 
movement  of  the  organ,  one  which  exposes  us  to  the  liability  of 
seizing  it  too  low  down.  The  speculum  is  then  readily  withdrawn 
alone,  as  the  forceps  can  pass  through  the  interval,  separating  the 
semi-cylinders.  The  first  thing  to  be  done  is  to  make  gentle,  slow, 
and  gradual  traction  upon  the  uterus  by  the’  aid  of  which  we  en- 
deavour to  bring  it  down  to  the  inferior  part  of  the  vagina,  first  in 
the  direction  of  the  axis  of  the  superior,  and  then  in  that  of  the  infe- 
rior strait ; but  in  order  that  the  uterus  may  be  more  completely 
taken  hold  of,  and  the  entire  circumference  of  the  inferior  portion  of 
its  neck  likewise  project  externally,  the  surgeon  applies  the  blades  of 
a second  pair  of  forceps  to  the  extremities  of  the  transverse  or  an- 
tero-posterior  diameters  of  the  organ,  according  to  the  direction  to 
which  the  first  has  been  applied. 

In  this  way,  whatever  tendency  the  uterus  may  have  to  resume  its 
position  in  the  abdominal  cavity  during  the  section,  the  tissues  main- 
tained in  situ  may  be  divided,  either  at  the  same  or  at  different 
heights,  according  to  the  pathological  condition.  The  index  finger 
being  now  carried  up  to  the  point  of  insertion  of  the  vagina,  easily 
recognized  by  the  presence  of  a kind  of  ring  above  which  pressure 
causes  an  empty  space  to  be  felt,  the  surgeon  confides  the  forceps  to 
an  intelligent  assistant,  who,  by  uniform  traction,  maintains  the  cervix, 
which  is  susceptible  of  a greater  or  less  prolapsus,  in  different  subjects, 


AMPUTATION  OF  THE  NECK  OF  THE  WOMB. 


349 


in  a proper  position.  The  assistant  should  stand  in  front  of  the  pa- 
tient, while  the  operator  must  be  placed  like  him  between  her  thighs, 
and  to  the  left,  holding  a curved  bistoury  cutting  upon  its  concavity, 
the  half  of  which  corresponding  to  the  articulation  of  the  blade  with 
the  handle,  must  be  covered  with  linen  within  about  an  inch  and  a 
half,  more  or  less,  of  its  blunt  extremity,  according  to  the  size  of  the 
cervix.  The  operator  directs  the  assistant  to  raise  the  forceps,  so  as 
to  give  to  the  inferior  portion  of  the  womb  a see-saw  movement,  which 
causes  the  posterior  part  of  the  neck  to  project  to  a greater  extent ; 
in  this  way  fhe  limits  of  the  disease  will  be  better  seen,  and  he  can 
cut  higher  up.  The  surgeon  now  glides  the  left  index  finger  semi- 
flexed  behind  the  os  tincae,  and  measures  with  this  finger,  the  palmar 
face  of  which  is  directed  downwards,  the  height  at  which  the  sec- 
tion ought  to  be  made  ; the  bistoury  is  placed  immediately  beneath 
it,  and  as  the  instrument  advances,  he  directs  and  gives  to  it  a point 
d’appui,  whilst  the  assistant  gradually  lowers  the  forceps,  in  order 
to  make  the  other  portions  of  the  cervix  uteri  project  in  their  turn, 
in  proportion  as  the  surgeon  cuts  at  different  heights.  It  ought  to  be 
well  understood,  as  the  disease  may  extend  higher  on  one  side  than 
on  the  other,  and  so  that  the  disease  may  be  completely  removed, 
that  the  assistant  must  be  directed  to  give  suitable  inclinations  to  the 
inferior  extremity  of  the  uterus  by  means  of  the  forceps,  and  espe- 
cially not  to  exert  too  strong  a traction  as  the  division  terminates, 
lest  the  tissues  be  torn.  The  bistoury,  moreover,  ought  to  advance 
by  sawing  movements,  and  with  gentle  strokes,  so  as  to  prevent  in- 
juries to  the  labia  majora,  irregularity  of  the  wound  and  dangerous 
slips.  This  part  of  the  operation  is  rather  difficult,  because  of  the 
resistance  which  the  tissue  of  the  cervix  uteri  in  its  natural  state 
presents. 

In  some  cases  the  cervix  is  too  large  to  be  received  into  the  spe- 
culum : we  are  then  obliged  to  remove  the  instrument,  and  conduct 
the  hooks  up  to  the  os  tincae  upon  the  finger. 

MODIFICATIONS  OF  THE  OPERATION  BY  THE  AUTHOR. 

In  order  to  avoid  the  employment,  at  the  same  moment,  of  two 
of  Muzeux’s  forceps,  which  we  are  compelled  to  confide  to  assist- 
ants, whose  hands  embarrass  the  manipulations,  and  especially  in 
order  to  seize,  in  every  direction,  readily  and  firmly  the  neck  of  the 

Fig.  37. 


uterus,  the  part  to  be  drawn  down,  we  invented,  in  1828,  a hook  with 
eight  claws,  which  approach  or  sepaiate  by  means  of  a central 


350 


AMPUTATION  OF  THE  NECK  OF  THE  WOMB. 


shank  fixed  upon  a slider,  arranged  in  the  form  of  a cross.  With  this 
instrument  called  by  us  the  utero-ceps , from  the 
Fig.  38.  Latin  words  uterus  womb  and  eapere , to  take,  a 
surgeon  may  operate  alone  ; he  may,  for  this  reason, 
execute  all  the  traction  more  uniformly,  and  finally 
direct  more  methodically  the  movements  of  elevation, 
descent  and  later&lity,  which  the  section  of  the  dis- 
eased parts  requires. 

The  handle  of  our  quadruple  hook,  which  is  made 
movable  by  means  of  a hinge,  ought  to  be  directed 
towards  the  anus,  so  that  the  hands  of  the  operator 
may  not  cover  the  entrance  of  the  vulva  and  the  in- 
terior of  the  speculum,  as  happens  when  the  forceps 
of  Muzeux  is  employed.  To  perform  the  amputation  of  the  neck  of 
the  uterus  with  the  utero-ceps , it  is  introduced  into  our  speculum 
or  any  other  multivalve  speculum,  then,  after  having  fixed  the  claws 
firmly  into  the  circumference  of  the  neck,  the  handle  is  bent  in  the 
direction  of  the  shanks  of  the  hook,  and  the  dilating  instrument  with- 
drawn as  done  by  M.  Lisfranc. 

After  the  removal  of  the  speculum,  we  give  to  the  handle  of  the 
utero-ceps  the  direction  which  it  had  had  at  first,  that  is  to  say,  it  is 
brought  back  again  towards  the  perineum,  in  order  to  accomplish 
the  descent  of  the  uterus  slowly  and  carefully,  and  according  to  the 
principles  we  pointed  out  above. 

The  operator,  in  using  our  forceps,  not  only  seizes  the  cervix  with 
a single  instrument,  but  he  has  also  much  less  occasion  to  fear  lace- 
ration, which  often  results  either  from  tractions  made  unequally,  and 
in  one  direction  rather  than  in  another,  or  from  the  fatigue  or  awk- 
wardness of  the  assistants,  who,  from  being  unable  to  keep  the  blades 
of  Muzeux’s  forceps  shut  for  a sufficient  length  of  time,  loosen  them 
so  much  as  to  allow  them  to  slip  from  the  cervix,  an  accident  of 
which  we  could,  cite  several  examples.  We  have  even  seen  a 
professor  of  the  Ecole  obliged  to  abandon  the  operation  after  this  un- 
fortunate accident,  which  unhappy  attempt  was  followed  by  intense 
nervous  symptoms,  and  a metro-peritonitis,  which  caused  the  death 
of  the  patient. 

If,  having  adjusted  the  hook,  it  should  be  found  impossible,  as 
often  happens,  to  bring  down  the  uterus  to  a level  with  the  vulva,  we 
must  not  for  that  reason  abandon  the  operation ; it  would  become 
necessary,  in  such  a case,  to  replace  the  speculum  without  removing 
the  utero-ceps,  and  then  make  the  section  of  the  neck,  either  with 
our  knives,  with  the  ends  formed  like  a hook,  or  with  extremely 
curved  scissors,  drawings  of  which  we  have  given  in  this  volume, 
[vide  cut).  We  might,  likewise,  make  use  of  these  two  last  instru- 
ments to  make  the  section  of  the  neck,  even  after  having  seized  it 
with  the  forceps  of  Muzeux. 

We  shall  conclude  by  saying,  that  in  operating  with  the  modifica- 
tions and  instruments  we  have  now  described,  we  have  no  occasion 
for  educated  assistants  who  have  frequently  witnessed  the  operation, 
and  who  can  be  found  only  in  the  large  hospitals  of  Paris. 


AMPUTATION  OF  THE  NECK  OF  THE  WOMB. 


351 


OF  HYSTEROTOMY  PERFORMED  WITHOUT  DISPLACING  THE  UTERUS. 

The  numerous  amputations  of  the  neck  of  the  uterus,  performed 
by  the  preceding  methods,  have  proved  that  the  tractions  exerted 
upon  the  organ  and  its  appendages,  rendered  the 
operation  generally  very  tedious,  and  always  dif-  Fig  39. 

ficult  and  painful,  while  the  section  of  the  neck 
scarcely  caused  the  patients  to  suffer  any  conside- 
rable pain,  and  was,  in  some  cases,  almost  unno- 
ticed by  them. 

These  motives,  the  difficulty,  and  even  impos- 
sibility, experienced  of  bringing  the  uterus  down, 
in  cases  of  soft,  fungous  and  fringed  cancer,  etc. ; 
the  decided  prolapsus  which  sometimes  results 
from  the  operation,  and  which  retards  or  presents 
the  cicatrization  of  the  wound  by  reiterated  fric- 
tions ; the  nervous  disorders,  and  all  the  unfa- 
vourable symptoms  which  depend  on  the  trac- 
tions, displacements,  violent  and  sudden  exten- 
sion of  the  tissues,  membranes,  ligaments,  nerves 
and  vessels*  not  only  of  an  organ  already  dis- 
eased and  inflamed,  but  also  of  several  other  or- 
gans, whose  anatomical  relations  are,  like  those 
of  the  womb,  more  or  less  changed ; the  danger 
of  perforating  the  vagina,  as  has  happened, 
while  operating  in  this  cavity  with  several  instru- 
ments which  we  shall  make  known;  and  finally 
the  hope  of  being  able  to  offer  a surgical  re- 
source for  a disease,  whose  nature  and  progress 
have  made  all  other  operative  methods  seem  in- 
applicable, have  suggested  to  us  the  idea  of  a 
method  of  hysterotomy  which,  acting  without 
the  exertion  of  traction,  seizes  and  cuts  at  the 
bottom  of  the  vagina  previously  dilated  by  means 
of  the  speculum,  the  cervix  uteri  at  the  proper 
height. 

Our  hystero/omisi,  which  name  is  derived  from 
the  Greek  words  vstspa,  womb,  and  tstivhr,  to 
cut,  is  a somewhat  complicated  instrument,  and  is 
composed  of  the  following  parts  : 

A steel  tube,  AA,  three  lines  in  diameter,  and 
six  inches  in  length,  terminated  at  one  of  its  ex- 
tremities by  a double-hooked  forceps  BB,  .the 
blades  of  which  are  approximated  in  such  a way 
as  firmly  to  seize  the  neck,  by  means  of  a shank 
CC,  designed  to  push  forward  the  movable  slider 
D,  which  should  shut  or  separate  the  grooved 
blades  of  the  hooked  forceps  BB.  The  shank  CC, 
which  traverses  the  whole  tube  A A,  traverses  like- 
wise the  ivory  handle  E,  which  is  terminated  by  a button  F,  by 


35  2 


colombat’s  operation. 


which  the  shank  CC,  to  which  it  is  fixed,  is  moved.  At  the  middle 
of  the  instrument  is  a copper  cylinder  G,  terminated  inferiorly  by  a 
kind  of  pulley  H,  upon  which  are  the  spring  I,  and*  the  hook  L, 
which  keeps  the  lever  M elevated,  and  which  rests  upon  the  enlarge- 
ment N of  the  cylinder  G,  serving  as  a guide  to  the  blade  0,  intended 
to  amputate  the  cervix  uteri.  This  lever  M,  which  is  raised  by 
pressing  its  extremity  P,  remains  fixed  to  the  hook  L.  It  is  mounted 
in  this  way,  and  as  we  now  describe  it,  the  hysterotome  ought  to  be 
introduced  into  our  speculum. 

DESCRIPTION  OF  THE  OPERATION. 

The  ..patient  should  be  placed  on  her  back  at  the  edge  of  the  bed  ; 
two  assistants  should  keep  the  legs  strongly  separated,  and  fix  the 
pelvis  in  such  a way  that  it  cannot  move.  The  legs  should  be  flexed 
upon  the  thighs  and  these  on  the  pelvis.  The  hips  must  be  so  ar- 
ranged as  to  be  slightly  elevated,  and  they  should  project  a little  over 
the  edge  of  the  bed. 

Every  thing  being  thus  arranged,  the  operator  proceeds  to  the  in- 
troduction of  the  speculum  uteri , and  then  after  confiding  the  handle 
to  an  assistant,  and  being  well  assured  that  the  os  tineas  i^  embraced 
in  the  instrument,  he  introduces  the  hysterotome , and  pushes  with 
the  right  hand  the  shank  CC,  which  causes  the  blades  and  claws  of 
the  hooked  forceps  BB,  to  approximate  and  seize  the  cervix  at  a 
greater  or  less  depth,  according  to  the  extent  of  the  disease.  Conti- 
nuing to  push  forward  the  shank  CC,  the  guide  cylinder,  by  means 
of  the  lever  M,  carries  the  blade  0 in  front  of  the  claws  of  the  for- 
ceps ; when  we  press  upon  the  two  stops,  P and  Q,  the  blade,  which 
is  attached  to  the  lever,  falls  suddenly  on  the  part  we  design  to  cut 
off,  thereby  imparting  a movement  of  rotation  to  the  cylinder  G;  the 
lever  M turns  around  the  neck,  which  is  amputated  circularly  by  the 
blade  0. 

Before  loosening  the  stops  P and  Q,  it  is  necessary  to  be  careful  to- 
draw  slightly  upon  the  uterus,  in  order  that  the  tissue,  being  made 
tense,  may  cut  more  readily.  The  instrument,  at  the  extremity  of 
which  is  fixed  the  portion  of  the  cervix  cut  off',  is  then  withdrawn,  and 
after  having  removed  the  speculum,  the  patient  is  placed  in  bed. 

We  are  far  from  pretending  that  our  method  of  operating  ought  to 
be  employed  in  all  cases;  we  think, on  the  contrary,  that  it  should  be 
used  only  in  certain  circumstances ; amongst  others,  when  the  woman 
is  extremely  nervous;  when  the  womb  is  very  high  up  and  not  very 
movable  ; when  the  neck  of  the  organ  is  soft,  friable  and  lacerated; 
and  lastly,  in  cases  where  the  other  methods  had  been  vainly  attempt- 
ed, and  when  they  would  seem  to  be  of  difficult,  tedious,  dangerous, 
or  altogether  impossible  application. 

When  the  womb  presents  the  opposite  conditions,  that  is  to  say, 
when  it  is  naturally  low  down,  movable,  and  sufficiently  consistent 
to  support  the  efforts  made  with  the  hooked  forceps,  we  think  that 
hysterotomy  should  be  performed,  by  drawing  down  the  uterus  with 
two  hooked  forceps,  or,  as  we  have  proposed,  with  our  own  hooked 


colombat’s  operation. 


353 


forceps  of  four  blades,  which  has  the  advantage  of  holding  the  cervix 
in  every  direction  and  very  firmly,  and  does  not  require  the  assist- 
ance of  other  hands  to  bring  down  the  womb,  or  the  aid  of  an  intel- 
ligent surgeon,  who  has  already  seen  the  operation  frequently  per- 
formed, and  who  can  be  procured  only  in  some  of  the  great  hospitals 
of  Paris. 

In  order  not  to  extend  our  remarks  too  far,  we  shall  give  merely 
the  most  important  details  of  the  different  operations,  the  three  first 
of  which  are  particularly  interesting,  on  account  of  the  very  consider- 
able size  of  the  tumours,  and  the  impossibility  of  removing  them  by 
the  ordinary  methods.  The  two  others  possess  no  interest,  except 
that  they  were  but  slightly  painful,  very  easily  performed,  without 
accident,  and  almost  without  consecutive  haemorrhage. 

Madame  Ch , aged  thirty  years,  was  of  a sanguine-bilious  tem- 

perament, with  brown  hair,  of  large  frame  and  good  constitution;  the 
mother  of  three  children ; affected  twice  with  syphilis,  communicated 
by  her  husband;  after  some  domestic  chagrin,  and  the  loss  of  a 
moderate  fortune,  she  found  herself  attacked  with  lancinating  pains 
in  the  groins,  loins,  thighs,  and  uterus.  Though  well  regulated 
before  the  appearance  of  all  these  symptoms,  she  had  experienced, 
for  some  time  past,  certain  irregularities  of  menstruation,  and  had 
uterine  haemorrhages,  so  frequent  as  to  be  almost  continual : a white 
discharge,  mixed  with  blood,  and  of  a fetid  odour,  always  accom- 
panied the  sanguine  effusions,  which  had  so  much  reduced  her 
strength,  that  it  was  almost  impossible  for  her  to  walk,  or  attend 

to  her  ordinary  occupations.  Madame  Ch , finding  that  none 

of  these  symptoms  diminished,  consulted  her  family  physician,  M. 
Bertrand,  who,  having  made  an  examination,  suspected  cancer  of 
the  cervix  uteri,  and  was  assured  of  it  by  means  of  a speculum, 
applied  by  Dr.  Berthelot,  who  had  been  called  in  consultation. 
The  cervix  was  very  large,  softened,  and  covered  with  numerous 
ulcerations  and  vegetations;  it  was  fringed  upon  the  edges,  and 
presented  all  the  characters-  of  an  enormous  cancerous  fungus.  The 
operation  by  our  method  being  regarded  as  the  only  means  of  safety 
which  remained  to  the  patient,  and  the  only  surgical  means  appli- 
cable in  the  case,  MM.  Bertrand  and  Berthelot  informed  me  of 
their  determination,  and  we  proceeded  to  the  operation  on  the 
fifteenth  of  November,  1828.  A few  moments  were  sufficient  to 
terminate  it,  notwithstanding  the  difficulties  we  had  to  surmount  in 
fixing  the  hooked  forceps  of  the  hysterotomist  into  the  cervix  uteri, 
which  was  two  inches  and  a half  in  diameter,  softened,  and  bathed 
in  blood.  Our  speculum  with  six  blades  was  employed,  and  its  in- 
troduction into  the  vagina  was  not  at  all  painful.  The  patient  told 
us  that  she  had  suffered  less  during  the  operation  than  when,  in  order 
to  explore  her  disease,  the  speculum  with  two  blades  had  been  ap- 
plied, A rather  abundant  haemorrhage  occurred  during  the  opera- 
tion, but  ceased  as  soon  as  Madame  Ch was  placed  in  bed.  None 

of  the  accidents  which  generally  take  place  occurred.  There  was  no 
syncope;  no  nervous  symptoms,  subsultus  tendinum,  or  delirium. 
Two  attacks  of  vomiting  followed ; we  had  taken  care,  in  order  to 
23 


354 


colombat’s  operation. 


prevent  fatiguing  efforts,  to  moderate  them  by  causing  the  patient 
to  drink  some  sweetened  water.  Not  a symptom  of  fever,  of  metritis, 
or  of  peritonitis  made  its  appearance ; a single  bleeding  was  per- 
formed the  day  after  the  operation,  on  account  of  a slight  increase 
of  the  pulse ; moreover,  the  patient  lost  so  little  blood  afterwards 
that  the  sheets  were  scarcely  soiled.  Eight  days  after  the  opera- 
tion, another  application  of  the  speculum  enabled  us  to  observe  a 
commencement  of  cicatrization,  and  a wound  of  the  finest  appear- 
ance. General  and  local  baths,  emollient  injections,  and  then  injec- 
tions of  chloride  of  lime  were  prescribed.  Strict  diet  was  observed 
from  the  first,  and  the  ordinary  drink  was  a ptisan,  made  of  pearl  bar- 
ley and  gum,  sweetened  with  lemon-syrup.  Twenty-five  days  after 
the  operation,  the  patient  was  entirely  cured,  and  the  cicatrization 
complete.  A lead-coloured  and  jaundiced  tint,  and  a sad  and  anxious 
expression  were  soon  replaced  by  a serene  and  well-coloured  counte- 
nance. Finally,  Madame  Ch , before  a month  had  elapsed,  could 

attend  to  her  occupations,  which  she  had  been,  for  a long  time,  obliged 
to  abandon.  In  order  that  no  doubt  might  remain  upon  the  nature 
of  the  alteration  of  the  cervix,  I showed  it  to  MM.  Dupuytren,  Reca- 
mier  and  Blandin,  as  well  as  to  a great  number  of  other  surgeons,  who 
were  of  opinion  that  the  portion  excised  was  of  carcinomatous  nature. 

Unfortunately  the  favourable  result  of  the  operation  did  not  pro- 
long the  life  of  Madame  Ch . As  she  had  evidently  a cancerous 

diathesis,  the  disease  showed  itself  again  ; not  in  the  uterus,  but  below 
the  urinary  meatus,  as  a scirrhous  tumour,  which,  preventing  the 
expulsion  of  the  uriue,  was  removed  by  Doctor  Berthelot ; the  car- 
cinomatous affection  afterwards  appeared  in  the  vagina,  and  extended 
step  by  step  to  the  gestative  organ,  where  it  had  commenced ; this 
patient,  however,  enjoyed  pretty  good  health  for  eight  or  nine  months 
after  the  operation,  and  it  was  not  until  fourteen  months  after,  that 
she  perished  from  the  return  of  the  disease.  At  all  events,  there  is 
no  doubt  that  the  operation  prolonged  her  life  at  least  a year. 

On  the  fifteenth  of  February,  1829,  we  were  called  to  Longjumeau, 
( Seine  et  Oise,)  by  Doctor  Guenee,  to  see  a woman,  thirty-six  years 
of  age,  who  was  affected  with  fungous  cancer,  of  very  considera- 
ble size,  seated  in  the  cervix  uteri,  and  extending  nearly  to  the  inser- 
tion of  the  vagina.  The  tumour,  extremely  friable,  soft  and  disor- 
ganized, was  the  seat  of  a fetid  discharge,  and  of  almost  constant 
haemorrhage.  In  spite  of  the  extent  of  the  disease,  and  the  difficul- 
ties we  should  have  to  encounter,  we  proceeded  to  the  operation, 
assisted  by  M.  Guenee,  physician  to  the  patient,  and  by  M.  Ducreux. 
Though  we  had  a good  deal  of  difficulty,  from  the  size  of  the  tu- 
mour, and  the  sanguine  discharge  which  took  place  in  adjusting  the 
hooked  forceps  of  our  hysterotomist,  the  diseased  portions  were  soon 
removed;  the  haemorrhage,  which  had  lasted  for  several  months, 
ceased  as  soon  as  the  patient  was  replaced  in  bed,  and  not  a nervous 
or  inflammatory  symptom  followed.  The  pulse,  which  was  frequent 
before  the  operation,  far  from  being  accelerated,  diminished  in  rapi- 
dity, and  the  patient  soon  recovered  her  strength,  appetite  and  ability 
to  sleep,  of  which  she  had  been  long  deprived  by  the  frightful  pain 
she  had  been  subject  to.  This  case  was  inserted  in  the  Lancettc 


colombat’s  operation. 


355 


Frangaise , vol.  i.,  No.  49;  the  tumour  was  seen  by  MM.  Breschet, 
Velpeau,  Fabre,  and  several  other  distinguished  physicians. 

We  also  performed  the  amputation  of  the  neck  of  the  womb  in 
another  case  nearly  similar  to  the  preceding.  The  tumour,  in  this 
case  also,  was  a very  friable  fungous  cancer,  presenting,  however, 
a rather  narrow  pedicle  springing  from  tissues  which  seemed 
healthy,  or,  at  least,  not  deeply  indurated.  The  operation  was  per- 
formed on  the  2d  of  June,  1830,  in  the  presence  of  MM.  Caignoux, 
Bonfils  and  Lachaise.  No  consecutive  haemorrhage  appeared ; the 
nervous  symptoms  were  confined  to  two  attacks  of  vomiting;  the 
fever  was  very  moderate,  and  the  patient,  who  was  twenty-eight 
years  old,  and  whose  disease  dated  more  than  fifteen  months  back, 
soon  recovered  perfectly ; the  cicatrization  of  the  wound  was  com- 
plete in  six  weeks:  finally,  up  to  the  2d  of  April,  1832,  the  epoch 

at  which  Madame  C died  from  an  attack  of  cholera,  she  had 

suffered  only  from  an  habitual  feeling  of  weight  in  the  pelvis  and 
some  rather  acute  pains  before  the  appearance  of  the  menstruae. 
The  excised  portion  was  shown  to  MM.  Breschet,  Cruveilhier, 
Blandin,  Recamier,  Dupuytren  and  several  other  practitioners,  who 
all  regarded  it  as  a cancerous  degeneration  of  the  cervix  uteri. 

The  excision  of  the  os  tincae  was  also  performed  by  us  with  entire 
success  on  a woman  twenty -six  years  of  age,  who  had  consulted  MM. 
Dubois,  Marjolin,  Boyer,  Lagneau,  and  her  relative,  Doctor  Sulp  . . . 
The  cervix  uteri,  without  being  very  voluminous,  was,  nevertheless, 
hypertrophied,  and  exhibited  an  ulceration  with  a hard  base,  of  a 
grayish  colour,  giving  rise  to  a fetid  ichorous  discharge  in  such  quan- 
tity that  a few  moments  sufficed  to  soil  several  napkins.  As  the  dis- 
ease continued  to  advance  and  had  resisted  every  means,  including 
a mercurial  anti-syphilitic  treatment  and  the  rob  de  Laffecteur,  we 
proposed  the  resection  of  the  neck,  which  was  performed  very  easily 
and  almost  without  pain,  on  the  13th  of  January,  1831,  in  the  pre- 
sence of  MM.  Deganose,  and  Doctor  Sulp , a cousin  of  the 

patient.  The  haemorrhage  was  rather  more  abundant  than  in  the 
preceding  cases,  but  there  were  no  consecutive  nervous  symptoms. 
The  cicatrization  was  complete  in  less  than  two  months.  This  lady, 
who  has  become  a widow  within  two  years,  continues  to  enjoy  per- 
fect health.  The  os  tineas  which  was  cut  off  was  presented  to  the 
Anatomical  Society  of  Paris. 

Lastly,  we  performed  the  operation  of  hysterotomy,  by  our  method, 
upon  the  wife  of  a cab-driver;  but  the  operation,  which  was  easy  and 
without  unfavourable  consecutive  symptoms,  did  not  prevent  the 
patient  from  dying  of  a relapse,  ten  months  after  the  excision  of  the 
affected  parts.  We  ought  to  state,  however,  that  the  cancerous  dis- 
order seemed  to  be  hereditary  in  the  case,  for  her  mother  died  from 
the  sequelae  of  a cancer  of  the  breast  which  had  been  extirpated  at 
the  Hotel- Dieu,  by  M.  Dupuytren.  " 

For  operating  at  the  bottom  of  the  vagina,  M.  Jules  Hatin  has 
proposed,  and  in  one  case  put  in  practice  a method  of  which  we  shall 
say  a few  words. 

The  operation  is  divided  into  two  periods ; in  the  first  is  applied 


356 


JULES  HATIN’s  OPERATION. 


the  speculum  with  three  blades,  which  can  be  opened  at  once  by  a 
screw,  and  which  allows  an  instrument  for  holding  the  cervix  and 
corpus  uteri  to  be  introduced  into  the  uterus.  This  instrument  is 
composed  of  three  shanks,  which  separate  from  each  other  when 
opened  in  the  uterus,  in  such  a way  as  to  fix  that  organ  and  make  it 
tense.  The  uterotomist  is  then  introduced,  which  is  composed  of  two 
separate  portions  united  by  means  of  an  articulation  similar  to  that  of 
the  forceps , in  the  middle  of  which  is  an  opening  to  allowsof  the 
passage  of  the  shank,  whose  extremity  is  within  the  cavity  of  the 
womb.  These  two  portions,  which  are  adjusted  one  after  the  other, 
and  united  within  the  speculum , carry,  at  their  uterine  extremity, 
two  crescentic  blades,  the  approximation  of  which  effects  the  section 
of  the  cervix. 

We  have  but  little  to  say  upon  the  method  of  Doctor  Canella, 
which,  in  our  opinion,  has  but  a single  inconvenience,  that  of  being 
inapplicable  to  any  case.  The  instrument  described  by  this  physi- 
cian in  the  Revue  Mklicale , more  than  two  years  after  the  publica- 
tion of  our  memoir  upon  the  amputation  of  the  neck  of  the  uterus, 
inserted  in  the  number  for  May,  1828,  of  the  same  journal,  is  com- 
posed of  a cylindrical  speculum,  into  which  is  introduced  a second 
speculum  armed  with  a blade,  designed  to  cut  the  cervix,  by  making 
the  tube  which  supports  it  revolve  on  its  axis.  A pair  of  Muzeux’s 
forceps  should  be  used  to  hold  the  organ  during  the  operation. 

ADVANTAGES  OF  THE  AUTHOR’S  METHOD. 

1.  By  making  the  incision  of  the  os  tincae  at  the  bottom  of  the 
speculum,  we  avoid  not  only  the  very  acute  pain  caused  by  the  trac- 
tions which  it  is  necessary  to  make  in  order  to  bring  the  uterus  to 
the  level  of  the  vulva,  but  also  most  of  the  secondary  nervous  symp- 
toms which,  according  to  our  observation,  seem  to  depend  less  upon 
the  section  of  the  organ  than  upon  its  displacement  and  the  sudden 
distension  of  its  ligaments.  The  secondary  haemorrhage,  likewise, 
has  always  been  slight  after  the  application  of  our  method,  and  has 
always  ceased  spontaneously,  which,  we  may  remark,  is  more  diffi- 
cult of  explanation  than  the  absence  of  the  secondary  nervous  phe- 
nomena. 

2.  There  is  less  cause  to  fear  metritis  and  peritonitis,  which  often 
result  from  the  violent  manipulations,  the  lacerations  and  the  trac- 
tions of  the  organ,  or  from  the  introduction  within  its  cavity  of  an 
instrument  designed  to  hold  or  draw  it  down,  as  performed  by  MM. 
Hatin,  Guillon  and  others. 

3.  It  is  not  necessary  to  renounce  the  operation,  as  has  often  been 
done,  when  the  neck  is  softened,  lacerated,  and  voluminous,  or  when, 
in  other  circumstances,  the  uterus  cannot  be  brought  down,  even  by 
the  most  methodical  tractions. 

4.  The  walls  of  the  vagina,  the  labia  majora,  and  all  the  neigh- 
bouring parts  protected  by  the  speculum,  are  not  exposed  to  the 
danger  of  being  wounded,  and  perforated  by  the  cutting  instrument, 
or  by  Muzeux’s  forceps. 


COLOMBAt’s  OPERATION — ITS  ADVANTAGES. 


357 


5.  Prolapsion  of  the  womb,  a consequence  of  tractions  exercised 
upon  the  organ,  not  occurring,  cicatrization  is  always  more  rapid, 
from  not  being  retarded,  and  rendered  impossible,  even,  by  the  re- 
peated frictions  which  the  inferior  portion  of  the  viscus,  in  an  unusual 
state  of  descent,  undergoes. 

6.  The  operation,  which  does  not  require  intelligent  assistants,  is 
more  rapid,  easier,  and  always  less  painful  than  by  any  of  the  other 
methods.  At  a single  blow,  especially  if  the  neck  be  not  very  large, 
we  remove  the  diseased  portions  which  have  been  carefully  explored 
by  means  of  the  touch,  the  speculum  and  our  concave  mirror,  with- 
out fear  of  the  accident  which  happened  to  the  professor  at  the  Ecole: 
in  this  case,  when  the  cervix  had  been  half  cut,  the  uterus,  which  had 
been  drawn  to  the  exterior  with  a great  deal  of  trouble,  returned  into 
the  vagina,  when  it  was  impossible  to  seize  it  again  in  order  to  finish 
the  operation,  the  effects  of  which  were  so  unfortunate  that  the  patient 
died  in  a few  days. 

Should  the  objection  that  we  are  unable  to  make  other  than  hori- 
zontal sections  be  brought  against  us,  we  reply,  that  inasmuch  as  hys- 
terotomy affords  some  chance  of  success  only  where  the  cancerous 
ulceration  does  not  extend  beyond  the  os  tineas,  our  method  is  always 
applicable  in  the  cases  which  are  much  the  most  common : besides, 
if  the  disease  should  extend  to  one  of  the  sides  of  the  neck,  we  think 
it  would  be  better  to  cut  transversely,  on  a level  with  the  diseased 
point,  in  order  to  be  certain  of  destroying  all  the  cancerous  germs, 
and  to  obtain  more  rapid  cicatrization,  the  wound  being  of  less  extent 
than  when  the  section  is  made  diagonally.  Moreover,  we  repeat., 
should  our  method  not  be  applicable  in  all  cases,  and  though  it  may 
often  be  necessary  to  prefer  that  of  M.  Lisfranc,  it  is,  as  we  have 
proved,  an  useful  addition  to  surgery,  and  a resource  to  which  prac- 
titioners might  have  recourse,  especially  when  other  methods  seem 
to  be  contra-indicated,  less  by  the  extent  of  the  disease  than  by 
certain  dispositions  of  the  parts  which  render  hysterotomy,  by  draw- 
ing down  the  organ,  of  difficult  and  often  impossible  application. 

Amongst  the  consecutive  phenomena  of  the  operation,  we  should 
include  different  nervous  symptoms,  which  alarm  persons  who  have 
never  witnessed  them.  They  are  generally  of  short  duration,  and 
rarely  last  more  than  two  or  three  hours,  especially  when  some  anti- 
spasmodic  is  administered  to  the  patient. 

The  blood,  which  often  flows  very  rapidly,  forms  a clot  which  fills 
the  vagina  and  occasions  tenesmus,  frequent  stools  and  ineffectual 
desires  to  urinate.  Sometimes  frequent  vomiting  comes  on,  or  eruc- 
tations, singultus  and  nausea,  which  occasion  great  suffering.  The 
contraction  of  the  abdominal  muscles,  and  the  shocks  which  they 
occasion,  expel  from  the  vagina  the  clot  which  had  arrested  the 
^haemorrhage.  The  blood,  which  flows  afresh,  relieves  all  these  symp- 
toms ; but  it  often  happens,  when  the  discharge  continues,  that  the 
face  becomes  pale  and  the  pulse  feeble,  and  vertigo,  trembling,  tinni- 
tus aurium,  subsultus  tendinum,  and  other  nervous  affections  make 
their  appearance  : finally,  syncope  often  follows,  which  causes  all  the 
phenomena  to  cease,  and  which  ought  the  less  to  disquiet  us,  as  it  is 


358 


AMPUTATION  OF  THE  NECK  OF  THE  WOMB. 


a means  which  nature  employs  to  arrest  obstinate  haemorrhage.  We 
should  restore  the  patient,  tranquillize  her,  but  avoid  the  use  of  the 
tampon,  unless  the  woman  is  threatened  with  death,  from  the  long 
continuance  of  the  bleeding  after  the  syncope. 

It  is  very  unusual  for  it  to  become  necessary  to  use  the  tampon ; 
but,  when  obliged  to  do  so,  it  should  be  left  only  a short  time  in  the 
vagina,  because,  by  the  pressure  which  it  exerts,  it  may  give  rise  to 
inflammation,  and  arrest  a sanguine  evacuation  capable  of  preventing 
or  diminishing  it,  if  it  already  exist. 

As  these  accidents  occur  several  hours  after  the  operation,  it  would 
be  very  imprudent  to  quit  the  patient  or  leave  her  alone  for  a single 
instant. 


AFTER-TREATMENT. 

Sometimes  the  phenomena  just  described  do  not  follow  the  opera- 
tion. When  the  blood  does  not  flow  in  sufficient  quantity,  we  have 
to  fear  a violent  attack  of  fever.  It  then  becomes  necessary  to 
examine  the  state  of  the  patient,  to  carry  the  finger  into  the  vagina, 
in  order  to  remove  the  clot  which  had  arrested  the  hgemorrhage,  and 
to  employ,  according  to  the  advice  of  M.  Lisfranc,  warm,  emol- 
lient injections.  Small  bleedings  from  the  arm  should  be  practised, 
at  longer  or  shorter  intervals,  as  the  state  of  the  pulse  permits  and 
the  other  symptoms  require.  These  small  bleedings,  which  are  also 
used  to  arrest  the  haemorrhage,  diminish  the  violence  of  the  fever 
very  much,  and  check  the  inflammation  which  is  developed  around 
the  wound  of  the  uterus. 

If  we  perceive  symptoms  of  gastro-enteritis,  and  if  the  patient  suffer 
from  pain  at  the  epigastrium,  it  becomes  necessary  to  apply  leeches 
to  that  part,  to  order  enemata  and  fomentations  of  flax-seed  mucilage, 
and  to  apply  emollient  poultices,  unless  the  abdomen  be  too  painful. 

After  some  days,  and  when  all  the  symptoms  have  disappeared, 
the  vagina  ought  to  be  well  washed  out  with  injections  of  marsh-mal- 
lows ; then,  when  the  irritation  has  entirely  passed  away,  and  the 
wound  seems  to  be  cicatrizing,  we  should  again  employ  injections, 
at  first  of  pure  water,  and  then  of  chloride  of  lime  in  solution,  gradu- 
ally increasing  its  strength.  This  kind  of  injection  powerfully  assists 
the  cicatrization,  which  is  often  retarded  by  the  white  discharges, 
to  which  almost  all  women  affected  with  diseases  of  the  womb  are 
subject. 

These  discharges  sometimes  continue  after  the  operation,  and  give 
rise  to  bleeding  granulations,  which  it  is  necessary  to  cauterize  with 
the  acid  nitrate  of  mercury.  Cauterization,  performed  in  this  way, 
not  only  destroys  the  fungous  granulations,  but  also  checks  the 
healthy  granulations,  whose  exuberance  prevents  the  cicatrization. 

For  several  days  after  the  operation,  the  patient  should  be  kept  on 
a rigorous  diet.  It  will  be  proper  to  recur,  from  time  to  time,  to 
revulsive  bleedings,  and  to  order  baths,  emollient  injections  and 
enemata.  When  the  cure  is  complete,  vve  should  prescribe  a mild 
regimen,  more  particularly  a vegetable  one : coitus  should  be  used 


AMPUTATION  OP  THE  NECK  OF  THE  WOMB. 


359 


with  the  greatest  moderation,  and  abstained  from  altogether,  in  case 
it  should  cause  acute  pain. 

We  shall  conclude  by  saying  that  amputation  of  the  neck  of  the 
uterus  is  an  operation  that  ought  to  be  resorted  to  with  the  great- 
est reserve,  and  only  as  the  last  resource,  in  cases  where  the  thera- 
peutical means  we  have  mentioned  have  failed  to  arrest  the  progress 
of  the  disease,  which  thus  renders  the  death  of  the  patient  inevitable. 
Yet  we  must  not  wait  until  the  cancerous  affection  has  implicated  the 
whole  cervix ; for,  independently  of  the  greater  danger  which  would 
result  from  the  operation  in  such  case,  relapse  would  be  almost  ine- 
vitable, should  the  disease,  having  spread  beyond  the  os  tincse,  require 
the  removal  of  the  whole  or  a great  portion  of  the  neck,  and  especially 
if  we  have  to  scoop  out  its  cavity,  as  most  practitioners  recommend. 
It  is  this  reason  that  renders  the  horizontal  sections  most  commonly 
suitable,  and  makes  our  method  applicable  and  sufficient  in  a large 
proportion  of  the  cases.  Besides,  if  portions  of  a suspicious  character 
remain,  it  would  always  be  easy  to  remove  them  by  means  of  our 
hooked  forceps  and  one  of  our  sickle  blades,  as  in  the  case  of  the 
woman  upon  whom  we  operated  at  Longjumeau. 

The  operation  offers  a better  chance  of  success  when  the  affection 
is  a primitive  ulceration,  resting  upon  a very  thin  indurated  layer, 
and  consecutive  to  a carcinomatous  degeneration.  The  fungous 
cancer , whose  pedicle,  whether  large  or  small,  is  fixed  by  shallow 
roots  in  the  os  tincse,  is  one  of  the  forms  of  cancer  least  disposed  to 
relapse,  after  the  excision  of  the  parts.  In  all  cases,  the  operation 
should  be  deferred,  so  long  as  the  disease  seems  to  remain  stationary, 
and  there  is  a hope  of  arresting  its  progress  by  any  other  means. 
Finally,  hysterotomy  should  be  absolutely  rejected,  when  the  lesion 
is  not  confined  to  the  cervix,  or  when  it  affects  other  organs  at  the 
same  time : it  is  well  also  to  take  into  consideration  the  hereditary 
predisposition,  the  course  and  duration  of  the  disease,  and  the  age 
and  constitution  of  the  patient.  Ulcerated  scirrhus,  encephaloid,  and 
hematode  cancer,  are  much  more  liable  to  relapse,  especially  if  there 
be  any  hereditary  predisposition.  We  ought  to  state  that  this  last 
circumstance  renders  the  reproduction  of  the  disease  almost  inevita- 
ble, and  generally  contra-indicates  the  operation. 

We  shall  conclude  by  remarking,  that  even  though  amputation  of 
the  cervix  uteri  should  not  succeed  more  than  once  in  six,  and  even 
once  in  twenty  cases,  it  would  nevertheless  be  a valuable  acquisition 
to  modern  surgery,  since  it  may  save  the  lives  of  women  devoted  to 
certain  death,  or,  at  least,  often  postpone  the  fatal  event.  We  may 
add  that  the  operation,  which  is  much  less  painful  and  less  dangerous 
than  cystotomy,  has  not  prevented  seyeral  women  who  have  under- 
gone it  from  becoming  pregnant  and  being  happily  delivered.*  If 

♦ Madame  Carpentier,  operated  upon  by  M.  Lisfranc,  has  had  four  children,  of 
■which  two  were  twins;  what  is  remarkable,  is,  that  before  the  operation  she  had 
never  conceived,  although  she  had  been  married  for  several  years.  In  this  case,  and 
in  some  others  that  we  might  cite,  it  is  probable  that  the  section  had  not  gone  much 
beyond  the  os  tincce. 


360 


EXTIRPATION  OF  THE  CANCEROUS  UTERUS. 


in  some  cases,  on  the  contrary,  obliteration  of  the  inferior  orifice  of 
the  womb  may  result,  and,  consequently,  an  obstacle  to  conception, 
and  to  the  flow  of  the  men  strum ; but  it  is  easy  to  prevent  this 
accident  by  the  introduction  of  a small  gum-elastic  bougie  into  the 
mouth  of  the  os  tincse,  when  we  examine  the  state  of  the  womb  and 
the  progress  of  the  cicatrization  by  means  of  the  speculum.  In  order 
to  perform  the  section  of  the  cervix  without  fear  of  haemorrhage, 
M.  Mayor,  of  Lausanne,  has  proposed*  the  ligature  applied  in  such 
a way  as  to  separate  the  diseased  portions  by  a strangulation  capable 
of  destroying  their  vitality  and  the  phenomena  depending  upon  it. 
It  is  useless  to  say  that  this  method  presents  too  many  inconve- 
niences and  too  many  difficulties  in  its  execution  to  have  met  with 
many  partisans;  besides,  the  haemorrhage,  which  M.  Mayor  seems 
especially  anxious  to  avoid,  prevents,  or  diminishes  when  it  is  mode- 
rate, the  inflammation  of  the  uterus ; in  case  it  should  be  too  abundant, 
we  might  make  ourselves  master  of  it,  either  by  means  of  plugging, 
or  by  cauterizing  the  open  vessels  which  furnish  the  blood,  with  a 
blunt  stilet  heated  to  a white  heat,  and  carried  up  to  the  wound  with 
the  aid  of  the  speculum. 

We  shall  speak,  also,  merely  to  make  mention  of  it,  of  the  cutting 
spoon  of  Dupuytren , which  is  inconvenient,  and  only  makes  sections, 
which  are  always  oblique,  unequal  and  ragged ; the  scissors,  curved 
in  a semi-lunar  form;  and  attached  at  a right  angle  to  their  handle, 
proposed  by  M.  Arronsohn,  of  Strasbourg,  have  the  inconvenience 
of  cutting  while  pressing,  and  especially  of  requiring  too  great  a sepa- 
ration to  allow  of  their  being  introduced  to  the  bottom  of  the  specu- 
lum and  embracing  the  cervix  uteri,  which  is  always  found  to  be 
enlarged  and  engorged  when  it  is  the  seat  of  a cancerous  affection. 

EXTIRPATION  OF  THE  CANCEROUS  UTERUS. 

Where  the  cancerous  degeneration  has  extended  its  ravages  to  the 
body  of  the  womb,  it  has  been  recently  proposed  to  perform  an  ope- 
ration for  its  complete  extirpation.  This  frightful  and  daring  opera- 
tion is  performed  in  several  different  ways  ; when  the  womb,  wholly 
changed  in  structure,  is  found  precipitated  without  or  beyond  the  ge- 
nital fissure,  three  different  modes  of  operating  may  be  discussed,  viz  : 
1st,  the  extirpation,  by  means  of  a ligature  passed  round  the  root  of 
the  tumour  formed  by  the  inverted  vagina.  2d,  by  a ligature  ap- 
plied in  the  same  manner,  but  followed  by  the  excision  of  the  tu- 
mour, beyond  the  constricted  point.  3d,  the  simple  excision  of  the 
part  with  cutting  instruments,  and  without  the  employment  of  the 
ligature.  As,  im  speaking  of  the  chirurgical  treatment  of  prolapsus 
uteri,  we  have  already  discussed  these  different  methods  of  effecting 
the  extirpation,  it  seems  unnecessary  to  recur,  at  great  length,  to  the 
subject  in  this  place  ; and  we  shall  be  satisfied,  therefore,  with  add- 
ing, that  the  last-named  mode  of  proceeding  labours  under  the  dis- 
advantage of  giving  rise  to  dangerous  haemorrhage,  and  of  admitting 

•Seance  de  l’Acad^mie  des  Sciences  da  19  Fevrier,  1827. 


EXTIRPATION  OF  THE  CANCEROUS  WOMB. 


361 


the  atmospheric  air  suddenly  within  the  peritoneal  sac,  an  event  that 
is  almost  invariably  followed  with  most  acute  inflammation  of  that 
serous  membrane.  While  the  first-named  operation  is  devoid  of  the 
danger  of  haemorrhage,  it  nevertheless  labours  under  an  objection,  that 
of  producing  severe  and  protracted  pain,  and  the  more  so,  as  the  stran- 
gulated womb  does  not  become  detached  for  several  days ; during 
which,  the  patient,  affected  by  the  putrid  odour  of  the  part,  is  liable 
to  the  most  alarming  nervous  disorders,  and  to  the  most  serious  in- 
flammatory attacks.  Both  of  these  methods  ought,  therefore,  to  be 
rejected,  in  favor  of  the  second-named  one,  viz  : the  application  of 
the  ligature,  and  the  excision  of  the  parts  beyond  it.  This  operation 
is  as  simple  as  possible;  it  moreover  avoids  the  haemorrhage,  the  lay- 
ingxopen  of  the  peritoneal  sac,  the  swelling  and  putrid  calluvies  of  the 
womb,  and  lastly,  most  of  the  severe  accidents  following  in  the  train 
of  the  other  operations. 

Whether  the  womb  be  found  already  prolapsed  beyond  the  vulva, 
or  whether  it  be  drawn  down  by  the  operator  himself,  we  ought  al- 
ways; previous  to  applying  the  ligature  to  the  neck  of  the  tumour, 
clearly  to  ascertain  whether  the  bladder,  or  a part  of  the  bowel,  has 
fallen  down  into  the  cavity  of  the  inverted  vagina  ; and  care,  more- 
over, should  be  taken  not  to  wound  those  organs:  this  is  done  by 
raising  the  woman’s  hips  a little  higher  on  the  bed  than  the  rest  of  her 
body,  and  by  getting  the  parts  well  out  of  the  way,  by  tapping  the 
hypogastrium  and  other  parts  somewhat  smartly  with  the  hand.  The 
surgeon,  with  a needle  armed  with  a double  silk  ligature,  of  suffi- 
cient strength,  now  transfixes  the  walls  of  the  vagina,  in  a direction 
from  front  to  rear,  and  removing  the  needle,  separates  the  ligatures, 
one  of  which  should  be  tied  firmly  on  the  right,  and  the  other  on  the 
left  side.  In  this  way,  the  strangulation  is  more  immediate,  and  the 
ligature  less  liable  to  slip  after  the  excision  of  the  womb  ; which,  as 
before  mentioned,  should  be  made  beyond  or  below  the  ligature. 

To  draw  down  the  non*prolapsed  womb,  with  a view  to  its  ablation, 
it  is  convenient  to  make  use  either  of  our  quadruple  hook  forceps, 
(vide  cut,)  or  of  a sort  of  hollow  sound,  to  be  passed  into  the  cavity  of 
the  womb,  the  walls  of  which  are  seized  by  four  small  hooks  that 
are  thrown  out  by  means  of  a screw,  at  the  lower  end  or  handle 
of  the  instrument.  This  sound,  which  is  moved  by  the  same  mecha- 
nism as  that  of  our  tire-tele , invented  by  us  in  1828,  for  experiment- 
ing, upon  the  dead  subject,  along  with  M.  Lisfranc,  who  was  then 
about  to  operate  for  the  total  extirpation  of  the  uterus,  should  be  used 
only  in  case  the  cervix  should  not  allow  of  a sufficient  hold  to  the 
hook-forceps,  and  where  the  interior  of  the  uterus,  as  yet  not  softened 
and  diseased,  could  admit  of  a firm  and  solid  attachment.  M. 
Guidon’s  instrument,  and  Professor  'R6camier’s,  which  are  analo- 
gous to  ours,  might  also  be  made  use  of ; but  they  cannot  be  so 
firmly  fixed,  nor  have  they  a graduated  scale  to  indicate  the  precise 
degree  of  separation  of  the  branches ; nor  can  they  be  introduced, 
or  withdrawn  so  readily,  from  the  greater  size  and  excessive  sali- 
ency  of  their  bent  extremities. 

Extirpation  of  the  ivomb  in  situ. — Where  the  rigidity  of  theliga- 


362 


EXTIRPATION  OF  THE  CANCEROUS  WOMB. 


merits  prevents  the  drawing  forth  of  the  womb,  which  makes  the 
operation  much  more  difficult,  longer,  and  more  hazardous,  its  total 
ablation  may  nevertheless  be  effected  in  two  different  ways.  The 
first,  which  is  called  the  hypogastric  or  surpubal  operation , was 
first  proposed,  and  methodically  described  in  1814,  by  M.  Gutberlat; 
this  method,  which  is  one  of  the  most  daring  attempts  of  modern 
surgery,  and  which  we  absolutely  protest  against,  under  all  circum- 
stances, consists,  in  the  first  place,  in  embracing  the  cervix  uteri  in  a 
sort  of  ring,  mounted  upon  a rod  and  handle,  so  as  to  fix  the  womb 
firmly  in  one  position  ; then  in  opening  the  abdomen  along  the  linea 
alba  sufficiently  to  admit  the  hand,  with  which  the  womb  is  to  be 
held  firmly,  while,  with  a scissors  in  the  right  hand,  he  cuts  away 
the  ligamenta  lata  and  rotunda,  and  the  superior  extremity  of  the 
vagina. 

This  operation,  the  most  dangerous  of  all,  yet  the  easiest  of  exe- 
cution, has  been  performed  on  the  living  subject,  by  Langenbeck,  of 
Gottingen,  and  also  by  Professor  Delpech.  Without  pointing  out  the 
modifications  of  the  method  introduced  by  these  two  distinguished 
surgeons,  we  shall  confine  ourselves  to  the  simple  remark,  that  both 
the  women  perished;  one  in  thirty-two  hours,  and  the  other  three 
days  after  the  operation. 

So  few  are  the  chances  of  success  presented  by  this  horrible  opera- 
tion, that  not  only  should  it  never  be  attempted,  but  even  the  works 
on  operative  surgery  should  notice  it,  only  for  the  purpose  of  utterly 
proscribing  it. 

The  ablation  of  the  womb,  in  situ,  by  the  sub-pubal  operation, 
was  performed  for  the  first  time,  in  1822,  by  M.  Sauter,  of  Constance, 
physician  to  the  Grand  Duke  of  Baden.  Previously  to  commencing 
the  operation,  he  emptied  the  bladder  and  rectum,  and  then  placing 
the  woman  as  recommended  for  the  excision  of  the  cervix  uteri,  and 
directing  an  assistant  to  press  the  womb  downwards,  and  at  the 
same  time  support  the  bowels,  after  driving  them  upwards  with  the 
edge  of  the  hand  applied  above  the  symphysis,  the  palm  looking 
towards  the  pubis,  “the  operator  introduced  the  left  index  and 
medius  into  the  vagina,  as  far  as  the  cul-de-sac ; he  next  passed  up 
a convex  bistoury  between  the  fingers,  and  cut  the  vagina  in  a circu- 
lar line  upon  the  cervix,  to  the  depth  of  two  or  three  lines ; he  next 
introduced  between  the  same  fingers,  a pair  of  scissors  curved  on  the 
edge,  with  which  he  separated  the  womb  from  the  bladder  up  to  the 
peritoneum,  bearing  hardest  on,  or  cutting  nearest  to  the  uterus. 
With  this  view,  he  made  use  of  his  fingers  to  pull  down  and  bring 
within  reach  of  the  scissors,  the  lowest  portions  of  the  cellular  tissue, 
so  as  to  cut  them  with  great  care.  This  is  an  easier  and  safer  mode 
than  to  use  the  concave  bistoury.  This  division,  carried  as  far  as  the 
peritoneum  inclusive,  ought  to  be  concluded  at  the  posterior  surface  of 
the  womb,  by  means  of  scissors  curved  on  the  flat,  the  concavity  look- 
ing towards  the  womb,  and  by  detaching  it  completely  from  the  rec- 
tum, so  as  to  permit  the  fingers  to  slide  up  along  side  of  the  womb  and 
penetrate  within  the  abdomen.  Having  gone  thus  far,  the  operator 
introduces  the  whole  of  the  left  hand,  the  palm  looking  backwards, 


EXTIRPATION  OF  THE  CANCEROUS  WOMB.  363 

• 

and  embracing  the  uterus;  with  the  index  and  medius  he  next  draws 
down  the  highest  of  the  lateral  attachments,  and  divides  it  with  the 
concave  bistoury,  which  should  be  gently  and  carefully  passed  up 
between  the  fingers.  The  same  division  is  effected  for  the  other  side, 
operating  upon  them  alternately,  so  as  to  be  enabled  to  make  the 
section  with  safety  on  both  sides,  while  the  womb  retains  its  position. 
It  is  hardly  necessary  to  say  that  every  successive  section  ought  to 
fail  upon  its  antecedent,  so  as  not  to  prolong  the  operation  uselessly. 

“ During  all  this  time  the  assistant  should  keep  his  hand  as  above 
directed ; when  the  extirpation  is  completed,  the  surgeon  will  find 
it  necessary  to  attend  to  the  bleeding.  It  may  be  that  not  much 
haemorrhage  will  attend  the  operation,  as  was  the  case  with  my 
patient,  and  as  ought  to  happen,  if  we  keep  close  to  the  womb, 
whose  blood-vessels  are  of  small  size,  as  I have  learned  by  much  re- 
search. Under  such  circumstances,  the  bleeding  demands  no  particular 
care,  but  if  it  should  appear  to  be  considerable,  or  give  rise  to  appre- 
hensions, a large  bundle  ofcharpie  should  be  immediately  introduced 
into  the  pelvis,  and  pressed  against  the  bowels,  after  which,  the  whole 
circuit  of  the  vagina  should  be  covered  with  large  pieces  of  prepared 
agaric,  filling  up  the  void  space  with  charpie;  this  simple  method 
seems  to  me  preferable  to  the  use  of  styptics. 

“After  this  dressing,  let  the  patient  be  put  to  bed,  and  kept  in  a 
horizontal  posture.  Not  until  this  is  done  should  the  assistant  cease 
to  restrain  the  downward  tendency  of  the  bowels  with  the  pressure 
of  his  hand. 

“Should  no  symptoms  supervene  foreign  to  the  natural  conse- 
quences of  the  operation,  the  case  requires  only  the  simple  precau- 
tions of  prudence.  Every  thing  must  be  avoided  that  might  tend  to 
force  the  bowels  down  into  the  excavation  of  the  pelvis;  and  all  that 
is  necessary  in  this  respect  is,  that  the  patient  make  no  change  in  her 
position  for  several  days.  Injections  into  the  vagina,  if  any  are 
deemed  requisite,  ought  to  be  made  with  gentleness,  that  they  may 
not  penetrate  into  the  abdomen.  The  same  kind  of  care  must  be 
taken  in  adjusting  the  charpie.  In  common  cases  these  precautions 
are  sufficient,  the  rest  must  be  left  to  nature,  whose  office  must  not 
be  interfered  with.’5 — ( Memoire  de  Sauter , traduit  par  le  Dr.  Pes- 
chier , of  Geneva , and  inserted  in  the  Melanges  de  Chirurgie  etran- 
gere,  1824.) 

The  woman  thus  operated  on  by  Sauter,  January  28th,  1824,  died 
four  months  afterwards.  M.  Hoelscher,  who  operated  in  the  same 
manner,  lost  his  patient  in  twenty-four  hours.  He  was  obliged  to 
cut  into  the  side  of  the  vagina,  in  order  to  introduce  his  hand  and 
facilitate  the  manoeuvres ; and,  in  order  to  guide  his  cutting  instru- 
ments during  the  act  of  separating  the  vaginal  insertion  into  the 
anterior  face  of  the  cervix,  he  passed  a sound  into  the  bladder.  Both 
of  the  patients  operated  on  by  M.  Siebold,  one  the  19th  April,  1S24, 
the  other,  July  25,  1825,  died,  one  in  sixty-five  and  the  other  in 
twenty-four  hours.  Those  of  M.  Langenbeck,  operated  on  January 
11th  and  August  5th,  1825,  also  perished  in  thirty-two  and  fifty 
hours,  respectively.  This  well-known  surgeon  made  an  incision  into 
the  perineum  from  before  backwards ; then,  after  dividing  the  vagina 


364 


EXTIRPATION  OF  THE  CANCEROUS  WOMB. 


posteriorly,  upon  the  sides,  and  in  front,  he  seized  the  womb  by  its 
fundus,  and  removed  it  entirely,  by  a careful  dissection. 

The  four  women  who  were  operated  on  by  Dr.  Blundell,  likewise 
perished.  The  first  one,  who  was  supposed  to  be  cured,  died  in  a 
year,  from  a relapse  of  the  cancer  ; the  second,  in  thirty-nine  hours; 
the  third,  in  nine  hours;  while  the  fourth  lived  only  a few  minutes. 
Dr.  Blundell  began  the  operation  by  detaching  the  vagina  behind ; 
and  after  penetrating  the  cavity  of  the  peritoneum,  between  the 
womb  and  rectum,  seized  the  i'undus  uteri,  which  he  retroverted 
towards  the  coccyx;  then,  dividing  the  broad  ligaments,  he  finished 
the  ablation  by  separating  the  organ  from  the  bladder,’ in  such  a way 
as  to  wound  neither  the  uterus  nor  the  neck  of  the  bladder.  The 
patient  on  whom  M Bauner  operated,  on  the  2d  September,  1828, 
died  on  the  fourth  day.  After  having  detached  the  womb  behind 
and  in  front,  and  cut  away  the  broad  ligament  upon  one  side,  he 
turned  the  organ  upon  its  opposite  side,  and  then  closed  the  operation 
by  separating  the  remaining  ligaments,  which,  up  to  that  period,  he 
had  left  untouched. 

M.  Lizars,  of  Edinburgh,  who  adopted  Langenbeck’s  operation,  in 
October,  1828,  also  lost  his  patient,  who  died  in  twenty-four  hours.  He 
made  an  incision  into  the  perineum,  but  prolonged  it  into  the  rectum; 
then,  having  turned  the  womb  over,  he  detached  it  from  the  vagina, 
before  and  behind.  Finally,  M.  Langenbeck,  who  operated  for  the 
third  time  in  1829,  by  the  sub-pubal  or  vaginal  method,  modified,  as 
has  already  been  explained,  was  not  more  fortunate  than  he  had 
been  upon  the  two  first  occasions;  for  his  patient  survived  only  four- 
teen days. 

M.  Recamier,  who  is  as  skilful  as  a surgeon  as  he  is  ingenious  and 
learned  as  a physician,  performed  the  first  operation  in  France,  for 
the  extirpation  of  the  womb,  July  29,  1S29 ; but  he  had  the  misfor- 
tune to  lose  his  patient,  after  the  lapse  of  a year.  M.  Recamier’s 
method  is  the  same  as  Sauter’s,  which,  by  means  of  some  important 
modifications,  has  been  rendered  more  methodical,  easy  and  safe. 
Where  the  descent  of  the  womb  has  been  found  to  be  practicable  by 
means  of  the  hook  forceps,  or  any  other  of  the  instruments  already 
described,  the  vagina  and  its  peritoneum  are  laid  open,  both  behind 
and  in  front  of  the  cervix,  in  such  manner  as  to  avoid  the  ureters 
and  the  fundus  of  the  bladder.  These  incisions  should  be  made  with 
a guarded  bistoury,  and  a probe-pointed  one,  carried  upwards  along 
the  fingers  to  its  extremity ; the  end  of  the  left  index  finger  is  next 
passed  into  the  opening,  and  serves  as  a conductor  to  the  probe- 
pointed  bistoury,  with  which  the  first  opening  is  extended  right  and 
left,  to  near  the  ligamenta  lata,  always  keeping  close  to  the  surface 
of  the  womb.  The  same  mode  is  followed  as  to  the  posterior  surface 
of  the  uterus,  which  now  remains  attached  only  by  its  sides.  At  this 
stage,  a ligature  is  passed  around  each  of  the  broad  ligaments  and 
secured  by  means  of  a serre  noeud.  Finally,  the  operation  is  brought 
to  a close,  as  in  prolapsus,  by  leaving  on  each  side  only  a sufficient 
portion  of  tissue  to  hold  the  ligatures. 

In  cases  where  the  womb  admits  of  no  hold  being  taken  of  it,  and 


EXTIRPATION  OF  THE  CANCEROUS  WOMB. 


365 


(he  rigidity  of  its  ligaments  renders  it  impracticable  to  draw  it  down, 
M.  Recamier  opens  the  vagina  behind,  after  the  manner  of  Sauter ; 
but,  for  this  purpose,  he  makes  use  of  a pharygotomist,  and  then,  car- 
rying Frere  Come’s  lithotomist  into  the  anterior  opening,  and  guiding 
it  by  the  left  index  finger,  extends  the  incision  along  each  side  of  the 
womb,  as  far  as  the  broad  ligaments ; and  lastly,  having  repeated 
the  same  manoeuvre  on  the  posterior  surface,  casts  a ligature  round 
each  of  the  ligaments,  which  are  then  cut  off,  near  the  uterus.  The 
viscus,  now  completely  severed  from  all  its  natural  attachments,  may 
he  seized  with  a hook  forceps,  and  easily  extracted  from  the  cavity 
of  the  pelvis.  It  is  proper  to  state  that  M.  Recamier  does  not  in- 
clude in  his  ligature  more  than  the  lower  third  of  the  broad  liga- 
ment, for  there  are  situated  the  principal  blood-vessels  of  the  womb. 
In  the  experiments  made  by  us  upon  the  dead  subject  in  the  Hospital 
de  la  Pitie,  we  made  use  of  a sort  of  probe-pointed  lithotomist,  which 
to  us  appeared  preferable  to  Frere  Come’s,  because  its  blade,  which 
cut  only  in  the  concavity,  was  less  likely  to  wound  the  adjacent  parts. 
For  the  adjusting  of  the  ligature,  we  employed  our  needle -forceps,  as 
being  more  convenient  and  easy  of  application ; by  which  the  needle 
was  passed  through  the  inferior  third  of  the  broad  ligament,  pre- 
viously to  commencing  the  division  of  it.  Lastly,  the  manoeuvres 
were  rendered  more  simple  and  easy,  by  means  of  a small  perineal 
incision,  which  greatly  enlarged  the  vulva,  and,  by  introducing  a 
small  sound  into  the  bladder,  for  the  purpose  of  protecting  that  organ, 
as  well  as  guiding  the  action  of  the  cutting  instrument. 

As  haemorrhage  would  be  rendered  impossible  by  the  ligatures, 
and  as  the  bowels  would  be  kept  above  the  pelvic  excavation,  by 
confining  the  patient  to  a horizontal  posture,  the  tampon,  in  any 
shape,  is  not  only  useless,  but  pernicious;  and  all  that  is  necessary  is, 
to  cover  the  vulva  with  emollient  stupes,  and  take  care  not  to  allow 
the  urine  to  flow  into  the  vaginal  cavity.  The  patient  should  be 
kept  in  a state  of  profound  repose,  and  the  only  remedies  should 
consist  of  antispasmodic  draughts,  cataplasms  and  fomentations,  in- 
jections, cooling  drinks,  and,  lastly,  blood-letting,  either  general  or 
local,  proportioned  to  the  strength  of  the  patient  and  the  nature  of 
the  symptoms. 

We  shall  not  describe  the  processes  of  Messrs.  Tarral  and  Gendrin, 
because  they  have  been  practised  only  on  the  dead  subject ; and  we 
shall  say  but  a few  words  on  M.  Dubled’s,  which  is  an  improvement 
on  the  partial  excision  of  the  body  of  the  uterus,  as  performed  in 
1828,  by  M.  Bellini,  as  follows : 

Having  drawn  the  organ  as  far  down  as  possible,  the  operator, 
with  a bistoury,  separates  the  vagina  from  the  cervix,  both  in  front 
and  behind ; then,  in  the  same  way  as  M.  Recamier,  he  secures  the 
lower  third  of  the  ligamentum  latum,  with  a ligature,  and  cuts  it  off 
close  to  the  womb.  As  the  viscus  now  holds  only  by  its  fundus 
adherent  to  the  peritoneum,  it  becomes  an  easy  matter  to  depress  it 
still  more,  and  remove  all  the  diseased  portions,  leaving  the  sound 
parts  behind.  M.  Dubted’s  patient,  operated  on  June  20th,  1830, 
survived  only  twenty-two  hours,  although  the  whole  of  the  womb 


f 


366  PHYSOMETRA. 

was  not  removed.  In  fine,  two  patients  operated  on  by  M.  Roux, 
one  by  M.  Delpech,  and  a second  case  by  M.  Recamier,  perished 
alike,  a few  hours  after  the  operation. 

This  statistical  and  funereal  record  of  extirpations  of  the  uterus, 
is  fitter  than  any  course  of  reasoning,  to  deter  the  practitioner  from 
so  redoubtable  an  attempt.  It  ought,  therefore,  to  be  rejected  from 
the  practice  of  surgery,  the  chief  aim  of  which  is  to  save  life  ; except, 
perhaps,  in  cases  where  the  womb,  already  partially  expelled  from 
the  pelvis,  and,  in  some  sort,  detached  from  the  rest  of  the  organism, 
may,  in  a sense,  be  said  to  have  lost  its  right  to  inhabit  the  cavity  of 
the  pelvis. 


PHYSOMETRA,  OR  TYMPANITIS  OF  THE  WOMB. 

The  term  physometra,  from  the  Greek  words  $voa,  gas,  and  /ujtpa, 
womb,  is  applied  to  an  affection  in  which  the  uterus  becomes  dis- 
tended with  air  or  gas,  either  extricated  within  or  accidentally  intro- 
duced into  its  cavity. 

The  presence  of  aeriform  fluids  within  the  womb  may  be  easily 
explained.  In  some  cases,  it  is  atmospheric  air  that  has  got  into  the 
viscus  through  the  os  uteri,  which  may  have  become  partially  dilated 
by  a pessary,  by  masturbation , by  coitus,  by  a diseased  conception, 
by  the  discharge  of  the  catamenia  or  some  unnatural  flux,  a transi- 
tory inertia  or  weakness  of  the  fibres,  a passive  haemorrhage,  partu- 
rition, &c.  Let  it  be  supposed  that,  in  this  condition,  a sudden  spasm, 
a coagulum,  a collection  of  mucus,  a falling  of  the  womb,  some  dis- 
placement, or  any  other  cause,  happens  to  close  the  orifice,  then  it  is 
easy  to  conceive  that  the  gaseous  fluid  may  become  rarefied,  may 
distend  the  walls  of  the  organ  that  contains  it,  and  escape  from  its 
imprisonment,  upon  some  sudden  motion  or  effort  made  by  the 
patient,  or  some  slight  pressure  on  the  hypogastric  region. 

In  other  instances,  the  gas  is  extricated  within  the  parietes  from 
some  chemical  action,  or  the  decomposition  of  coagula  of  blood,  or 
of  portions  of  the  placenta  left  after  delivery ; or  of  a putrid  foetus, 
retained  within  the  uterus.  Whenever  it  happens,  under  such  cir- 
cumstances, that  the  torpor  and  atony  of  the  womb  prevent  it  from 
contracting  and  expelling  the  aeriform  fluids  within  it ; when  the  os 
uteri  becomes  spasmodically  contracted,  or  is  obstructed  by  a mem- 
brane, by  a scirrhous  tumour,  or  a polypus,  or  any  other  of  the 
causes  heretofore  enumerated,  symptoms  of  physometra  become 
manifest ; and  they  are  variously  designated  by  the  terms  uterine 
tympany , uterine  pneumatosis , flatulent  pregnancy  and  wind- 
mole. 

Little  is  known  of  the  nature  and  constitution  of  the  gases  deve- 
loped within  the  womb.  If  we  imagine  the  gas  to  be  generally  a 
sulphuretted  hydrogen,  we  judge  so,  not  from  a chemical  analysis, 
but  from  its  odour ; and  especially,  from  the  colour  it  communicates 
to  the  flame  of  a candle.  Leduc,  the  surgeon,  was  witness  to  a very 
remarkable  circumstance  in  this  relation : he  had  scarcely  withdrawn, 
with  his  crotchet,  the  putrid  body  of  a foetus,  when  there  escaped, 


PHYSOMETRA. 


367 


with  impetuous  force,  a quantity  of  gas,  smelling  of  sulphur,  and 
which  burned  with  a violet-coloured  flame.  Baudelocque  mentions 
a case  in  which  a very  fetid  gas  escaped  as  he  was  introducing  the 
first  blade  of  his  forceps.  M.  Deveux  states  that  having  removed  a 
clot  that  filled  the  mouth  of  the  womb,  an  offensive  gas  escaped, 
with  explosion, from  the  vulva;  and  another  instance  of  a like  kind, 
upon  removing  a portion  of  the  membranes  that  occupied  the  os 
uteri.  A fact  of  a very  remarkable  character,  in  pathological  anatomy, 
was  observed  by  Baudelocque,  as  he  was  about  to  proceed  to  the 
autopsy  of  a female  who  died  in  labour, — a loud  explosion  of  gas  from 
the  vulva  took  place,  and,  at  the  same  time,  the  foetus  was  expelled 
with  violence.  Torally  also  reports  a very  curious  case,  in  which  the 
womb  itself  was  inverted  and  pushed  out  of  the  body  ; which  must 
have  been  caused  by  the  very  considerable  extrication  of  gas  in  the 
bowels. 

Although  the  formation  of  gases  in  the  uterine  cavity  is  mostly 
produced  by  the  decomposition  of  the  foetus,  placenta,  or  various  collec- 
tions of  blood,  or  other  fluids  amassed  within  it,  it  cannot  be  denied, 
that  in  some  of  the  instances,  the  aeriform  gases  are  the  products  of 
an  inappreciable  morbid  exhalation.  This  essential  kind  of  physo- 
metra  has  been  described  and  observed  by  several  writers,  among 
whom  are  Franck,*  Mauriceaut  and  Delamotte.  The  Revue  Mbdi- 
cale , 1830,  t.  iv.  p.  484,  quotes  a case  from  a Bolognese  work.f  A 
woman,  forty  years  of  age,  who  had  never  borne  any  children,  ima- 
gined herself  pregnant,  because  her  menses,  always  regular  previ- 
ously, had  become  suddenly  suppressed,  while  the  abdomen  enlarged, 
so  that  the  womb  had  reached  the  fifth  month  of  development, 
mounting  upwards  as  high  as  the  navel.  The  os  uteri  was  perfectly 
closed,  and  the  uterus  could  be  completely  circumscribed  by  means 
of  moderate  pressure  with  the  hands.  Such  was  her  condition,  when 
all  the  hopes  of  the  pregnancy  vanished;  one  day,  upon  stooping 
down,  a great  quantity  of  flatus  suddenly  escaped  from  the  womb  ; 
the  belly  was  reduced,  and  after  some  days  recovered  its  natural  size. 
We  are  acquainted  with  a lady,  twenty-eight  years  of  age,  who  had 
been  declared  by  several  physicians  pregnant,  and  who  met  with  a 
similar  disappointment  while  making  a movement  to  get  upon  her 
bed. 

The  distension  of  the  womb  by  gases,  although  a rare  disorder, 
was  also  observed  by  many  ancient  authors,  among  whom  we  may 
cite  Valescus  de  Taranta,§  J.  M.  de  Gradibus,||  Thaddeus  Dunus,1T 
Rembertus  Dodonseus,**  Ph.  Hcechstetter,tf  Mauritius  de  Cordibus,f  f 

* Epit.  de  curand.  morb.  de  retent.,  t.  i. 

f Traite  des  mal.  des  femmes  grosses,  t.  i.  p.  74. 

$ Opusc.  della  Societd,  Med.  Chirurg.  di  Bologna,  t.  iv. 

§ Philonium.  et  Chirurg.  de  Med.,  lib.  vi.  cap.  15. 

||  Practica,  seu  Commentar.  in  Nonum  Rhasis  cap.  de  mola. 

1 Mulier.  morb.remed.  miscell.  cap.  8. 

**  Medicinalium  observationum,  exempia  rara,  obs.  49. 

-j-j-  Rariorum  observat.,  decade  v.  obs.  4. 

$$  Hipocratis  de.  mulier.  morb.  interp.  et  explic.  in  lib.  i.  comment,  3. 


368 


PHYSOMETRA. 


Ambrose  Pare,*  Ph.  Salmuth,t  Reinier  Solenander,±  Astruc,§  and 
others. 

. From  cases  noticed  by  all  the  authors,  uterine  pneumatosis  has 
been  more  frequently  met  with  in  women  who  have  had  children 
than  in  virgins.  It  has  been  thought  that  the  age  from  forty  to  fifty 
years  is  the  one  in  which  it  mostly  occurs,  and  that  persons  of  a ner- 
vous temperament  are  most  subject  to  it.  Sauvage  tells  us  of  a hys- 
terical woman  whose  physometra  always  disappeared  shortly  after 
the  occurrence  of  her  catamenia. 

Authors  have  distinguished  t wo  kinds  of  physometra, — the  dry  and 
the  humid.  In  the  former,  which  is  generally  transitory,  the  womb 
contains  nothing  but  gas,  and  does  not,  in  general,  surpass  in  size 
the  volume  of  the  gravid  uterus  of  the  third  month.  The  latter  or 
humid  physometra,  is  so  called  because  the  womb  contains,  not  gas 
only,  but  also  a variable  quantity  of  fluid,  which  may  be  serous,  clear, 
turbid,  muddy  and  fetid  ; this  species,  which  was  observed  by  Bene- 
dicti,||  De  Vega,Tl  Laurent  Jourbert,**  Portal,  Franck,  &c.,  and  which 
acquires  a more  considerable  magnitude,  since  it  is  often  mistaken 
for  pregnancy,  is  distinguished  from  the  former  by  the  weight,  mass 
and  fluctuation  of  the  tumour.  Franck  says  that  the  gas  occupies 
the  upper  part  of  the  tumour,  and  that  by  making  the  woman  change 
her  position,  the  womb  changes  its  form,  and  gives  out  a gurgling 
sound. 

The  same  author  remarks,  that  by  taking  the  womb  betwixt  both 
hands,  the  sensation  of  a bladder  filled  with  air  is  felt,  and  which  is 
much  more  sonorous  above  than  below.  We  may  also  ally  with  the 
physometric  disorder,  two  other  varieties  that  were  noted  by  Franck. 
He  says,  ( loc . citat.,)  that  a physician  in  Lorraine  published  a case 
in  which  a bladder  full  of  air,  (or  a wind-mole)  suddenly  escaped  from 
the  womb  and  fell  upon  the  floor,  bounding  like  a ball.  He  also  tells 
of  a Dutch  woman  who,  after  being  long  subject  to  floodings,  dis- 
charged a fleshy  mass,  containing  a number  of  vesicles,  some  of 
which  were  full  of  a yellowish  serum,  and  others  with  a gaseous 
fluid. 

[I  have  been  closely  attentive  to  the  complaints  of  patients  under  my  care 
as  to  physometra,  and  I rest  under  the  conviction,  that  the  cases  of  the  dis- 
order that  have  fallen  under  my  notice  during  the  last  thirty  years,  are  not 
strictly  entitled  to  the  appellation  of  physometra.  It  is  true  that  I have  been 
conscious  of  the  discharge  of  gas  from  the  uterus , yet  never  but  on  one 
occasion,  and  that  was  during  an  embryotomy  operation  for  a woman  with 
distorted  pelvis,  who  was  twice  afterwards  subjected  to  the  Caesarian  opera- 
tion, in  this  city.  In  that  case,  the  placenta  was  absolutely,  when  I removed 
it,  putrid,  black,  and  emphysematous  from  the  extrication  of  the  putrid  gas 

* CEuvres,  livre  xxiv.  chapitre  xc. 

f Observat.  medic,  centuriae,  centur.  ii.  obs.  57. 

* Concilior.  medicinal  sectioned  quinque. 

§ Traite  des  maladies  des  femmes,  t.  iii.  p.  377. 

II  De  Curandis  morbis.  lib.  xxv.  oper.  omn.  1539. 

^ De  Morbis.  medend.  libri  tres,  sect.  10,  cap.  32, 1576. 

**  Operum.  Latin,  cap.  13,  de  urinis. 


PHYSOMETRA. 


369 


in  its  texture.  I was,  I say,  conscious  of  the  discharge  of  gases  from  this 
uterus,  but  they  were  the  gaseous  products  of  a putrefying  after-birth — not  a 
disease  of  the  womb,  nor  at  all  fit  to  be  called  a uterine  disorder,  but  a mere 
accidental  extrication  of  putrid  gases  from  a foetus  and  placenta  in  putrefac- 
tion; this  is  the  only  case.  As  I have  been  a great  many  years  very  busily 
occupied  in  obstetric  practice  and  in  the  treatment  of  female  complaints,  I 
should  be  supposed  to  have  had  good  opportunities  of  becoming  acquainted 
with  the  disease  called  physometra  did  the  case  really  exist,  except  as  an 
accident  upon  the  mechanical  obturation  of  the  os  uteri  or  vagina. 

I do  not  perceive  how  a person  of  such  good  judgment  as  M.  Colombat, 
can  admit  that  a gaseous  fluid  could,  under  any  other  circumstances,  be  capa- 
ble of  filling  the  uterus.  A gaseous  fluid  would  escape  from  the  os  uteri 
under  the  contractility  of  texture  of  the  uterine  fibre  alone;  and,  a fortiori , 
under  that  of  the  womb  and  abdominal  muscles  together — particularly  since 
every  inspiration  of  the  breath  finds  its  antagonist  force  at  the  floor  of  the 
pelvis.  The  pressure  of  such  antagonism  would  always  expel  the  gas  from 
the  uterus.  Its  stay  in  the  womb  would  be  impossible. 

It  is  true,  however,  that  I am  accustomed  not  unfrequently,  after  labours, 
to  hear  loud  explosions  of  air  from  the  vagina  ; but  I do  not  regard  them  as 
the  results  of  a true  physometra,  as  I suppose  they  consist  of  portions  of 
air,  ingurgitated  into  the  loose  and  flaccid  walls  of  the  vagina,  upon  the 
cessation  of  the  expulsive  effort  of  the  womb  immediately  after  the  escape 
of  the  foetus.  The  womb,  in  this  stale,  is  jammed  down  to  the  bottom  of 
the  pelvis  almost,  as  the  child  goes  forth  from  its  cavity — and  as  soon  as 
the  tenesmic  effort  is  suspended,  it  rises  again  to  its  place,  and  acts  in  the 
manner  of  a piston,  drawing  after  it  into  the  vagina  a portion  of  air,  which 
is  again  expelled  when  the  woman  renews  her  effort  at  bearing  down  for 
the  delivery  of  the  placenta.  This  is  the  mode  in  which  I account  for  the 
noise  so  frequently  heard  upon  the  woman’s  making  a bearing-down  effort. 
I delivered  a patient  of  a child  at  seven  o’clock  this  morning,  Nov.  14,  1844. 
It  was  a case  with  adherent  placenta.  The  patient  bore  down  with  great 
force  until  the  whole  of  the  child  was  expelled,  and  of  course  the  globe  of 
the  womb,  containing  the  undetached  placenta,  was  pushed  very  low  down, 
in  order  to  chase  the  foetus  quite  out  of  the  body.  As  soon  as  the  effort 
ceased,  I heard  a great  sound  as  of  the  ingurgitation  of  air  which  rushed  into 
the  loose  vagina  and  the  expanding  womb.  In  a short  time  afterwards  I 
compressed  the  lower  belly  with  my  hand,  to  promote  the  expulsion  of  the 
placenta — and  upon  doing  so,  I forced  the  ingurgitated  air  to  rush  out  again, 
♦with  amphoric  sound  nearly  as  great  as  that  made  by  its  ingurgitation.  But 
is  this  accident  at  all  worthy  to  be  called  physometra,  a dynamic  state,  and  fit 
to  establish  a belief  in  the  power  of  the  inner  walls  of  the  womb  to  excrete 
gaseous  fluids?  The  same  thing  is  true  of  the  supposed  physometra  of  the 
non-gravid  female,  or  of  the  woman  two  or  three  months  gone  with  child.  If 
she  happen  to  have  a loose  and  flaccid  vagina,  with  a heavy  womb,  that  organ 
24 


370 


PHYSOMETRA. 


descends  more  or  less,  from  her  being  long  on  foot — and  then,  when  she  lies 
down,  it  again  ascends  to  its  place,  drawing  imperceptibly  after  it,  enough  air 
to  occupy  the  vagina.  If  now  she  should  cough  or  sneeze,  or  make  pressure 
on  the  hypogaster,  or  suddenly  get  up  from  the  couch,  the  air  is  as  suddenly 
expelled,  with  more  or  less  sound.  Such  is  the  explanation  of  this  occur- 
rence I have  been  accustomed  to  give  to  the  patient,  who  is  generally  found 
to  be  much  distressed  with  so  unusual  and  disagreeable  a phenomenon,  and  I 
have  always  explained  it  by  the  same  rationale  to  my  classes,  in  the  public 
lectures  at  the  Medical  College.  I cannot  but  add,  that  I have  never  known 
it  to  take  place  except  in  women  somewhat  low  in  health,  and  of  weak  and 
relaxed  fibre,  excepting  always  the  instances  following  labour,  where  the 
state  of  the  woman’s  general  health  is  indifferent  in  the  calculation;  the 
strongest  and  the  weakest  subjects  seeming  alike  liable  to  the  occurrence. 
Franck’s  citation  of  the  Lorraner  who  saw  a ball  full  of  air  bounding  on 
the  floor,  must  be  deemed,  I fear,  as  in  the  apocrypha  of  physic;  and  old 
De  Vega,  Joubert  Valescus  de  Tarenta,  Mathaeus  deGradibus,  and  even  faith- 
ful old  Pare,  are  not  of  sufficient  authority  to  settle  this  point  in  the  affirma- 
tive. What  satisfies  me  is,  that  the  canal  of  the  cervix  uteri  is  always  free 
to  admit  a full-sized  bougie — and  to  emit  the  menstrual  secretion  pleno  rivo. 
Who  shall  convince  me  that  it  shall  become  air  tight?  Not  even  M.  Bau- 
delocque  himself,  who  is  the  magna  parens  of  scientific  midwifery. 

The  Bulletin  of  Med . Sciences , by  Dr.  Bell,  for  Sept.  1844,  p.  309,  con- 
tains an  article  on  Physometra,  of  which  the  following  are  extracts.  The 
article  is  from  the  British  and  Foreign  Review.  “M.  M.  Stoltz  and  Nae- 
gele,  two  of  the  most  celebrated  practitioners  in  the  diseases  of  females 
of  the  present  day,  at  the  Medical  Congress,  held  at  Strasbourg,  in  1842, 
expressed  their  belief  that  tympanitis  of  the  uterus  was  impossible ; and 
that  the  alleged  cases  of  its  occurrence  were  apocryphal.”  The  article 
contains  remarks  on  several  cases  seen  by  M.  Lisfranc,  and  proceeds  to 
say  that  “ M.  Lisfranc  does  not  appear  to  have  seen  any  case  in  which 
tympanitis  was  purely  dynamic , that  is,  independent  of  the  presence  of 
any  extraneous  substance  in  the  womb.”  Dr.  Waller,  ( Lectures  on  the 
Functions  and  Diseases  of  the  Womb , p.  75,)  seems  to  admit  of  the  disorder, 
as  he  says,  “ The  constitution  of  those  who  suffer  from  this  disease  is  very 
generally  weak  and  delicate,  a collection  of  air  in  the  cavity  of  the  womb 
not  being  the  only  symptom  under  which  she  is  suffering,  but  one  in  com- 
mon with  many  others.  The  air  appears  to  be  secreted  by  the  menstruating 
membrane  of  the  uterus ; for  if  pregnancy  occurs,  the  disease  is  for  a time, 
if  not  permanently,  cured.”  To  think  of  the  womb  “ secreting ” air  ! — M.] 

The  symptoms  of  physometra  consist  in  a feeling  of  uneasiness  and 
tension  in  the  hypogastric  region ; the  woman  complains  of  a pain, 
beginning  in  the  womb,  and  running  off  towards  the  groins,  loins, 
thighs,  and,  in  some  instances,  even  to  the  diaphragm.  In  most  cases 
the  menses  are  suppressed,  yet  there  are  some  women  who  continue 


PHYSOMETRA. 


371 


to  have  them  regularly.  The  abdomen,  which  enlarges,  presents  a 
uniform,  circumscribed  tumour,  tense,  and  resounding  upon  percus- 
sion like  a drum.  The  womb,  which  gradually  rises  above  the  pubis, 
tends  towards  the  umbilicus,  and  may  even  reach  above  it,  does  not 
increase  in  weight,  though  having  acquired,  as  in  many  instances, 
considerable  magnitude.  This  evolution  is  sometimes  accompanied 
with  thirst,  anorexia,  rigors,  and  slight  fever,  increasing  generally 
towards  evening : the  excretions  of  stool  and  urine  are  more  or  less 
disordered;  the  patient  has  some  respiratory  uneasiness;  becomes 
inactive,  dislikes  to  move,  and  it  is,  indeed,  not  uncommon  for  the 
uterine  distension  to  excite  sympathetic  action  of  the  breasts,  which 
swell,  and  even  secrete  a sort  of  milky  fluid. 

In  this  state  of  things,  the  expulsion  of  a portion  of  gas  from  the 
vulva  gives  relief;  and,  generally  speaking,  an  abundant  discharge 
of  it,  which  is  commonly  accompanied  with  noise,  dissipates  all  the 
symptoms  of  the  malady.  This  sort  of  uterine  eructation  may 
happen  at  very  various  periods  : it  is  rare,  however,  for  the  gas  to  be 
retained  within  the  womb  beyond  five  or  six  months.  Under  such 
circumstances,  the  menses  not  returning,  the  woman  is  apt  to  suppose 
herself  pregnant,  and  the  more  so,  as  the  feelings  she  experiences 
resemble  those  occurring  in  pregnancy. 

A case  of  physometra  could  hardly  be  mistaken  for  pregnancy, 
except  during  the  three  or  four  first  months:  in  fact,  from  that  period, 
the  little  alteration  that  takes  place  in  the  cervix  uteri ; the  absence 
of  the  ballottement  (tilting;)  the  lightness  of  the  tumour;  the  daily 
differences  perceived  in  the  form  and  size  of  the  tumour ; the  reso- 
nance on  percussion;  the  negative  stethoscopic  signs;  the  rapid  in- 
crease of  the  abdomen ; the  absence  of  the  motions  of  a child  in 
utero,  &c.,  should  leave  no  doubt  in  the  mind  as  to  the  nature  of 
the  affection.  An  error  would  be  absolutely  unpardonable,  should 
the  woman  be  of  an  age,  or  in  a situation,  to  render  it  improper  for 
her  to  conceive. 

[I  have  seen  some  cases  of  supposed  pregnancy,  in  which  medical  gentle- 
men, of  sufficient  information,  had  allowed  themselves  to  be  deceived,  and 
permitted  the  patient  to  go  to  the  end  of  the  supposed  term  before  the  error 
was  ascertained.  Yet,  in  all  these  cases,  and  they  have  been  many,  I never 
allowed  myself  to  suppose,  even  for  a moment,  that  the  womb  was  the  seat 
of  the  flatulent  development;  and  I entreat  the  younger  reader  to  distrust 
M.  Colombat’s  remarks  as  to  the  results  of  the  sur-pubal  percussion,  above 
stated;  because,  though  he  may  find,  in  such  case,  the  sonorous  percussion, 
I conceive  he  will  have  no  ground  to  infer  that  the  resonance  is  uterine,  and 
not  intestinal.  I must  also  take  so  great  a liberty  with  the  author,  as  to 
re-assert  my  disbelief  (vide  p.  368)  in  the  existence  of  the  malady  he  has 
so  fully  described ; I look  upon  it  as  a pathological  impossibility ; I repeat 
that  the  supposed  gases  could  not  be  retained  in  the  womb,  except  under  an 
absolute  imperforation  of  the  vagina  or  cervix  ; and,  in  such  event,  there 
could  be  no  such  gases  extricated  or  expelled.  I confidently  believe  that 
where  the  womb,  under  physometra,  has  been  thought  to  extend  up  to  the 


372 


PHYSOMETRA. 


navel,  there  has  been  a mistake  of  diagnosis,  or  a voluntary  deception  on  the 
part  of  the  patient.  Such  mistake,  or  such  deception,  is  easy  to  be  made, 
since  the  bladder,  when  filled  with  urine,  could  easily  be  mistaken  for  the 
uterus  itself,  and  yet  yield  a sonorous  percussion  from  the  transmitted  reso- 
nance of  the  intestines  behind  and  below  it. 

Finally,  I regard  the  cases  of  physometra  as  likely,  all  of  them,  to  prove, 
upon  a careful  diagnosis,  to  be  cases  of  chronic  tympany  ; an  affection  so 
common  in  nervous  and  hysterical  women,  as  to  be  frequently  met  with  in 
practice.  Having  offered  these  remarks,  I continue  the  translation  of  M. 
Colombat’s  article,  of  which,  let  the  reader  judge,  as  follows. — M.] 

The  diseases  with  which  physometra  may  be  confounded,  are 
to  be  divided  into  three  classes.  The  first  comprises  the  affections 
that  consist  in  increase  of  size  of  the  womb  itself,  as  pregnancy ; 
dropsy  of  the  womb  ; accumulation  of  blood,  or  a collection  of  hy- 
datids within  the  organ ; a polypus  or  mole ; concretions,  whether 
calculous,  lymphatic  or  sanguine  ; hysteria,  &c.  In  the  second  class 
are  comprised  the  morbid  changes  that  supervene  in  the  uterine  ap- 
pendages ; such  as  scirrhus  and  dropsy  of  the  ovary  ; ovarian  and 
tubal  pregnancy  ; and,  lastly,  in  the  third  class  are  arranged  divers 
abdominal  disorders,  such  as  ascites,  intestinal  and  peritoneal  tym- 
pany, purulent  collections  and  tumours  of  the  omentum,  of  the  mesen- 
tery, or  of  the  abdominal  parietes.  Though  the  number  of  these 
affections  is  very  considerable,  all  ridiculous  as  well  as  serious  mis- 
takes will  be  avoided  by  attending  to  the  origin  and  progress  of  the 
disease,  and  by  prevailing  on  the  patient  to  submit  to  the  slightest 
examination.  Besides,  le  pet  vaginal  would  furnish  a very  conclu- 
sive sign,  could  its  existence -be  ascertained. 

It  must  likewise  be  remembered  that  a physometra  may  not  only 
co-exist  with  a hydrometra,  but  that  these  disorders  may  alternate 
with  each  other,  particularly  as  they  appear  to  arise  from  the  same 
causes,  acting  in  different  degrees.  In  the  case  of  hydrometra,  the 
development  of  the  abdomen  proceeds  gradually,  while,  in  physo- 
metra, it  is  commonly  sudden.  In  the  latter,  the  tumour,  which  is 
more  elastic,  recovers  its  size  quicker,  and  gives  rise,  upon  pressure* 
to  the  sensation  of  a bladder  filled  with  air  and  squeezed  with  the 
hands. 

For  the  most  part,  the  prognosis  in  physometra  is  not  very  grave  ; 
if  there  be  any  danger  in  the  case,  which  is  often  very  protracted, 
that  danger  arises  less  from  the  malady  itself  than  from  the  patholo- 
gical lesions  and  alterations  that  give  birth  to  it,  and  of  which  it  is 
but  a secondary  symptom : even  where  it  is  essential,  it  constitutes 
rather  an  inconvenience  than  a real  disease. 

The  treatment  of  physometra  consists  in  fulfilling  the  two  chief 
indications  of  giving  issue  to  the  aeriform  fluids,  and  preventing 
their  development  or  their  introduction.  As  pneumatosis  of  the  organ 
may  depend  upon  the  numerous  causes  we  have  mentioned,  we  ought 
first  to  try  to  ascertain  what  they  are.  Should  the  formation  of  the 
gases  and  the  obstruction  of  the  os  uteri  depend  upon  a fastus,  a pla- 


PHYSOMETRA. 


373 


eenta,  a portion  of  membrane,  or  a fibrinous  clot  in  a state  of  putre- 
faction, and  retained  within  the  womb,  we  should  follow  M.  Deneux’s 
example,  and  remove  the  obstruction  with  the  point  of  the  finger, 
and  then  prescribe  injections  of  emollients  and  chlorides.  Should  the 
physometra  be  complicated  with  a polypus  too  large  to  be  extracted 
without  aid,  we  might  adopt  Dupuytren’s  method,  of  slitting  the 
cervix  uteri,  either  from  without  inwards,  or  vice  versa ; yet  we  are 
of  opinion  that,  in  order  to  obtain  a sufficient  enlargement,  without 
carrying  the  incision  too  far,  it  would  be  preferable  to  make  several 
small  incisions  into  the  circumference  of  the  os  uteri.  In  case  the 
tympany,  whether  essential  or  introduced  into  the  womb  from  with- 
out, be  deemed  to  depend  upon  spasmodic  constriction  of  the  neck, 
or  on  inertia  of  the  uterine  fibres,  we  should,  in  the  former  state, 
order  emollient  uterine  injections,  baths,  and  fumigations;  opiate 
draughts,  and  anodyne  injections  into  the  rectum ; after  which,  by 
the  use  of  the  speculum,  portions  of  belladonna  ointment  might  be 
carried  up  to  the  cervix  uteri,  or  introduced  into  the  vagina  as  far 
as  the  os  tinea?,  which  should  be  titillated,  while,  with  the  other 
hand  on  the  hypogastrium,  pressure  is  made  on  the  womb,  so  as 
to  press  out  the  gas  In  the  latter  case,  which  is  when  the  tym- 
pany depends  upon  inertia  of  the  womb,  directions  ought  to  be  given 
for  the  employment  of  tonic  drinks,  of  stimulating  frictions  for  the 
abdomen,  and  of  small  doses  of  ergot,  to  excite  the  uterus  to  con- 
traction. Where  the  woman  seems  weak,  which  is  common,  her 
strength  should  be  sustained,  not  as  to  the  womb  only,  but  as  to 
the  general  system,  by  chalybeate  medicines  and  ferruginous  waters, 
decoctions  of  cinchona,  pills  of  quinine,  gentian,  and  other  tonic  arti- 
cles; by  stimulating  frictions  and  vinous  fomentations;  by  placing 
hot  flannel  on  the  hypogastric  region,  which  is  of  much  use  in  the 
treatment.  We  might  also  condense  the  gas  in  the  womb,  and  at 
the  same  time  increase  the  irritability  of  the  viscus  by  covering  the 
region  of  the  uterus  with  a bladder,  filled  either  with  ice  or  with 
cold  water. 

For  a strong  patient,  young  and  plethoric,  blood-letting,  general  or 
local,  may  be  beneficial.  After  trying  all  other  remedies  in  vain,  and 
clearly  ascertaining  the  non-existence  of  pregnancy,  and  especially 
should  any  bad  consequences  happen  to  follow  the  collection  of  gas 
in  the  organ,  it  might  be  withdrawn  by  gently  introducing  a flexi- 
ble catheter  into  the  cavity  through  the  canal  of  the  cervix.  It  would 
be  well  to  attach  to  the  outer  extremity  of  the  catheter  an  empty 
bladder,  in  order  to  collect  the  gases  expelled,  for  the  purpose  of  sub- 
jecting them  to  a chemical  analysis.  After  their  evacuation,  attempts 
should  be  made  to  prevent  a relapse,  by  the  use  of  baths,  lotions, 
douches  and  tonic  injections,  or  the  injection  of  anodynes,  opiates, 
emollients,  detergents  and  chlorides,  according  to  the  indications  and 
circumstances  of  the  case.  With  a view  to  determine  the  expulsion 
of  gases  from  the  womb,  it  has  also  been  recommended  to  use  pur- 
gative medicines,  leaping,  dancing,  and  different  kinds  of  violent 
exercise.  Such  methods  ought  to  be  rejected,  as  well  as  all  sorts  of 
carminatives,  which  are  rather  injurious  than  useful. 


374 


HYDROMETRA. 


We  shall  conclude  by  observing,  that  there  is  another  kind  of 
pneumatosis  of  the  female  sexual  organs,  called  by  writers  CEdoco- 
phy * garrulitas  vulvas  and  pet  de  la  vulve.  CEdocophy,  which  is 
rather  an  inconvenience  than  a disease,  is  the  expulsion,  more  or 
less  noisy,  of  gases  contained  in  the  vagina.  These  aeriform  fluids 
may  get  into  the  passage  through  a recto-vaginal  fistula,  or  directly 
through  the  vulva,  during  the  separation  of  the  labia  pudendi.  Ac- 
cording to  Franck,  this  troublesome  complaint  is  more  frequent  than  is 
generally  supposed ; and  the  reason  why  physicians  rarely  hear  of 
it,  is  that  women,  from  a feeling  of  modesty,  dislike  to  make  their  in- 
firmity known ; it  is  apt  to  occur  in  coitus  in  'such  patients.  Lame 
women,  who  limp  in  their  walk,  appear  to  be  most  subject  to  it, 
probably  from  the  alternate  dilatation  and  closing  of  the  passage 
while  moving  on  foot. 

[I  shall  finish  this  article  by  quoting  a passage  from  Madame  Boivin 
and  M.  Duges,  Pract.  Treat,  on  Disease  of  the  Uterus , p.  134.  It  is  in  the 
following  words.  “ We  have  never  known  the  existence  of  an  aeriform 
body  in  the  uterus,  except  in  obstetric  cases,  as  in  retention  of  the  mem- 
branes, or  of  portions  of  the  dead  foetus,  or  of  putrefied  coagula,  causing 
gaseous  exhalations  found  in  the  uterus  after  death,  or  escaping  per  vagi- 
nam  during  life.”  It  is  true,  that  they  add,  at  p.  136  : “ The  symptoms  of 
physometra  are  too  characteristic  to  admit  of  any  doubt,  after  careful  exa- 
mination,” &c.  I merely  wish  to  remark,  that  the  immense  public  and  pri- 
vate practice  of  the  authors,  ought  to  have  made  them  acquainted  with  phy- 
sometra, were  it  really  a disease. — M.] 


OF  HYDROMETRA,  OR  DROPSY  OF  THE  WOMB. 

Hydrometra  is  a very  rare  disorder,  and  consequently  but  little 
known  ; it  is  nothing  more  than  a collection  of  serous  or  sero-mucous 
fluid  in  the  cavity  of  the  uterus. 

The  causes  of  the  disorder  are  a feeble  constitution  debilitated  by 
floodings,  by  profuse  and  protracted  leucorrhoea,  by  miscarriages, 
by  frequent  hysterical  attacks,  a fall  or  blow  on  the  hypogastrium, 
an  acute  or  chronic  metritis,  or  any  cause  capable  of  keeping  the 
womb  in  a state  of  debility  or  protracted  irritation.  We  ought  to 
add,  that  although  such  causes  may  give  rise  to  a considerable  secre- 
tion of  fluid  into  the  cavity  of  the  uterus,  an  attack  of  hydrometra 
cannot  occur  unless  the  os  tincae  be  closed,  either  by  the  cohesion  or 
swelling  of  the  labia  of  the  os  uteri,  or  from  fungoid  tumours,  a 
polypus,  or,  in  a word,  anyone  of  the  obstructions  we  enumerated 
in  our  article  on  physometra.  Although  cases  of  hydrometra  are 
very  rarely  met  with,  they  would  be  still  more  uncommon,  should  we 
comprise  under  that  denomination  only  the  real  instances  of  a pro- 
duction and  retention  of  serous  fluids  within  the  cavity  of  the  womb. 
But  the  disorder,  which  is  not  met  with  in  virgins,  is  symptomatic, 
and  is  found  to  follow  various  alterations  and  inflammations,  whether 


a ihia,  the  sexuat  organs,  and  xc<t>ev,  crepitum  edo. 


HYDROMETRA. 


375 


acute  or  chronic  of  the  uterus.  In  such  cases,  the  fluid,  instead  of 
being  bland  and  limpid,  is  found  to  be  thick,  foetid,  bloody,  opaque, 
and  somewhat  similar  in  appearance  to  coffee  grounds  and  to  lotura 
carnium.  Schenck,  of  Nuremburg,  in  his  valuable  collection  of 
cases,  (lib.  iv.,  case  220,)  published  A.  D.,  1600,  takes  notice  of  this 
sort  of  symptomatic  hydrometra,  and  of  the  brown,  muddy,  foetid 
liquor  contained  in  the  organ. 

Under  the  title,  therefore,  of  hydrometra,  has  been  comprehended 
any  collection  in  the  womb,  consisting  of  fluid,  whether  serous,  albu- 
minous, sero-mucous,  or  purulent,  whose  quantity,  colour  and  con- 
sistence vary  according  to  the  causes  producing  them.  Sometimes 
the  cavity  contains  scarcely  a pound  or  two  of  fluid,  and  at  other 
times  it  is  found  to  be  distended,  so  as  to  give  rise  to  a belief  that 
the  patient  is  pregnant,  or  labouring  under  ascites.  Blankard*  re- 
lates the  case  of  a woman,  whose  uterus  contained  eighty-five 
pounds  of  ichorous  and  oily  matter.  Vesalius,  (opera  omnia,)  says, 
he  examined  the  body  of  a woman  whose  uterus  contained  sixty 
measures  of  water,  of  three  pounds  each.  Theophilus  Bonnett 
quotes  several  cases  not  less  curious,  and  John  Schenck, ± who  died 
in  1588,  asserts  that  he  found  a womb  large  enough  to  contain  a child 
ten  years  of  age. 

Symptoms. — The  size  of  the  abdomen  increases  with  more  or  less 
rapidity,  and  the  swelling,  which  commences  in  the  middle  of  the 
hypogastrium,  gradually  extends  from  below  upwards.  During  the 
first  months  the  woman  supposes  herself  pregnant ; the  breasts  either 
lessen  or  increase  in  size;  the  countenance,  which  is  bloated  and  pale, 
bears  the  impress  of  languor ; she  has  a feeling  of  weight  in  the 
pelvis,  pains  in  the  loins,  dragging  sensations  in  the  groins,  and  some- 
times a slight  degree  of  fever.  By  the  touch,  we  discover  a rounded 
and  firm  tumour  in  the  hypogastrium,  which  appears  to  come  up 
from  the  pelvis,  to  a certain  height,  greater  or  less.  The  position  of 
this  tumour  is  very  little  changed  by  the  changes  of  her  position,  and 
we  find  a deep-seated,  obscure, circumscribed  fluctuation  in  it;  but 
the  least  equivocal  sign  is  that  ascertained  by  Touching  : in  fact,  by 
introducing  a finger  into  the  vagina  as  far  as  the  cervix  uteri,  and  then 
pressing  the  tumour  with  the  other  hand,  we  readily  feel  the  shock 
of  a fluid,  and  a very  distinct  fluctuation.  This  is  not  a symptom 
of  ascites  nor  of  dropsy  of  the  ovaria,  or  tubes;  for  in  those  affec- 
tions, the  cavity  of  the  uterus  is  not  distended  with  fluid,  but  the 
organ  is  itself  jammed  down  towards  the  bottom  of  the  pelvis  with- 
out any  increase  of  size. 

The  diagnostic  characters  of  hydrometra  may  be  supposed  some- 
what more  obscure  from  the  rarity  of  the  opportunities  for  studying 
them ; and  as  it  may  be  confounded  with  pregnancy,  particularly  in 
the  early  months,  it  is  of  the  utmost  importance  not  to  mistake  the 
symptoms  of  one  for  the  other  condition.  Such  errors,  which  might 
have  the  most  serious  consequences,  may  be  avoided  by  calling  to 

* Anat.,  &c.;  sive.  de  cad.  morbis  de  nat.  anatom,  inspectio,  1688. 

f Sepulchretum,  seu  anat.  pract.,  lib.  iii.  sect.  xxi.  case  55,  16S8. 

* Obs.  med.  rarum.  nov.  admir.  et  monstr.  volumen  lib.  iv.,  obs.  6. 


376 


HYDROMETRA. 


mind  the  fact  that  in  dropsy  of  the  womb  there  is  absence  of  bal- 
lottement  which  is  ascertained  by  Touching,  and  that  the  abdominal 
palpation  and  auscultation  by  the  stethoscope,  reveal  neither  foetal 
movements  nor  beatings  of  its  heart.  Finally,  the  absence  of  reso- 
nance in  the  tumour,  and  its  fluctuation  will  not  admit  of  its  being 
mistaken  for  a case  of  pneumatosis  of  the  womb.  It  is  equally  im- 
portant not  to  confound  the  disease  in  question  with  a collection  of 
blood  in  the  organ.  The  symptoms  we  have  given  of  the  latter, 
at  page  89,  would  soon  remove  all  uncertainty  upon  this  point. 

The  prognosis  of  hydrometra  varies  with  the  causes  of  the  malady: 
in  general,  it  is  not  so  unfavourable,  when  a portion  of  the  fluid  is 
allowed  from  time  to  time  to  escape,  as  happens  in  some  instances. 
Fernel,  who  was  physician  to  Henry  II.,  mentions  a case  of  dropsy 
of  the  womb,  which  disappeared  once  a month,  and  was  renewed 
after  each  mensual  evacuation.*  Generally  speaking,  the  disorder  is 
not  very  dangerous,  and  whenever  it  does  give  rise  to  any  apprehen- 
sions, they  are  derived  from  the  circumstances  which  have  occa- 
sioned it,  and  from  the  frequent  repetition  of  relapses.  In  some 
cases  it  ceases  towards  the  term  of  gestation,  or  the  evacuation  takes 
place  about  the  third  or  fourth  months,  and  in  such  cases  it  often 
happens,  according  to  Mauriceau  and  Nauche,  that  the  disease  re- 
turns no  more. 

When  the  liquid  is  limpid  and  inodorous,  we  find,  on  examination 
after  death,  the  lining  membrane  of  the  womb  nearly  in  a natural 
condition.  Where  the  collection  is  thick,  purulent,  ichorous  and 
foetid,  the  mucous  membrane  of  the  womb  exhibits  traces  of  chronic 
inflammation  and  ulceration  of  different  kinds. 

Hydrometra  is  more  frequently  met  with  in  pregnant  than  in  non- 
gravid  women.  Here  the  symptoms  of  the  uterine  dropsy  are  con- 
founded with  those  of  gestation.  The  abdomen  is  larger  than  in  a 
simple  pregnancy ; the  dyspnoea  is  also  greater  and  more  distressing; 
the  lower  extremities  are  oedematous,  and  the  infiltration  often  ex- 
tends over  the  whole  body.  The  motions  of  the  child  are  commonly 
obscure,  the  cervix  is  higher  up  in  the  pelvis  from  the  greater  deve- 
lopment of  the  womb,  and  the  child,  following  the  impulsion  of  the 
mother’s  movements,  is  tilted  in  every  direction  in  the  midst  of  the 
waters. 

As  few  occasions  have  offered  of  examining  the  body  after  death 
with  hydrometra  during  gestation,  authors  are  far  from  agreeing  as 
to  the  seat  of  the  morbid  fluid  in  pregnant  persons.  Mauriceau, 
Puzos,  and  Mess.  Itard  and  Nauche,  together  with  some  other  wri- 
ters, have  placed  it  between  the  chorion  and  the  internal  surface  of 
the  womb  ; M.  Nsegele,  and  some  other  persons,  supposed  the  collec- 
tion to  be  formed  betwixt  the  laminae  of  the  caduca ; others,  again, 
like  M.  Duges,  imagine  that  the  fluid  of  hydrometra  (in  pregnancy) 

* Marcellus  Donatus,  (Medic,  histor.  mirabil.  lib.  iv.,  cap.  25,)  and  D.  Monro, 
Essay  on  Dropsy,  p.  164,  say  that  they  have  observed  the  menstruation  to  be  regular 
in  women  labouring  under  hydrometra  ; this  phenomenon,  of  which  Donatus  himself 
gives  an  explanation,  could  be  derived  only  from  a sanguine  exhalation  from  the  va- 
gina and  os  tincse,  as  takes  place  in  certain  cases  of  gestation. 


HYDROMETRA. 


377 


is  contained  in  the  sac  of  the  allantois,  betwixt  the  chorion  and  am- 
nios. As  all  these  opinions  are  founded  only  upon  theory  and  inge- 
nious explanations,  all  of  them  debatable,  we  conclude  that  the 
question  is  still  open,  and  likely  to  continue  so  for  a long  time. 

The  treatment  of  hydrometra  consists,  at  first,  in  combating  the 
organic  disease  of  the  womb,  of  which  it  may  be  only  a secondary 
symptom.  Where  the  affection  is  essential,  the  womb  appearing  to 
be  sound,  and  clearly  not  gravid,  we  may,  for  the  purpose  of  giving 
a shock,  in  accordance  with  the  advice  of  Monro  and  Astruc,  and  most 
other  authors,  have  recourse  .to  the  drastics,  to  emetics,  to  sternuta- 
tories, or  to  irritating  injections,  and  to  vaginal  injections  of  the  same 
kind,  with  a view  to  excite  the  uterine  contractions.  It  should  be 
observed,  however,  that- before  resorting  to  the  measures  above  indi- 
cated, it  would  be  well  to  soften  or  relax  the  cervix  uteri  as  much  as 
possible,  by  means  of  baths  and  emollient  and  narcotic  injections 
and  fumigations.  Some  broken  doses  of  secale  cornutum,  exhibited 
conjointly  with  an  application  of  belladonna  ointment  to  the  os  tincae, 
might  probably  be  prescribed  with  advantage  where  the  cervix  is 
soft,  and  the  obstacle  to  the  discharge  of  her  waters  does  not  consist 
of  a polypus,  or  a scirrhous  tumour,  but  is  due  solely  to  the  inertia 
or  the  spasmodic  constriction  of  the  neck  of  the  womb. 

In  some  cases,  a finger,  a blunt  stilet,  or,  still  better,  a straight  silver 
or  gum-elastic  bougie  introduced  into  the  os  uteri,  has  been  em- 
ployed to  open  the  orifice  and  procure  the  discharge  of  the  fluid.  In 
case  - the  obstacle  should  consist  of  a polypus  that  could  not  be 
pushed  out  of  the  way  with  the  point  of  a finger,  we  should  try  to 
penetrate  to  the  cavity  of  the  womb  with  a flat  catheter,  passing  along 
the  side  of  the  polypus,  the  subsequent  removal  of  which  might  lead 
to  a radical  cure. 

Should  these  measures,  as  sometimes  happens,  prove  to  be  inef- 
ficacious, a trocar  might  be  made  use  of  to  puncture  the  womb. 
Francis  Wirer*  performed  the  operation  successfully,  by  passing  the 
trocar  an  inch  and  a half  above  the  pubis,  and  at  the  same  distance 
from  the  linea  alba.  Fifty-three  pounds  of  a thick,  blackish,  bloody 
liquid  escaped  through  the  canula ; steady  pressure  was  afterwards 
kept  up  with  Monro’s  bandage  and  several  napkins ; the  patient,  who 
was  fifty  years  of  age,  was  completely  cured  ; for  ten  months  after 
the  operation,  there  was  no  return.  The  sub-pubal  puncture  was 
also  performed  with  advantage  by  Noel  Desmarais,  in  a case  of 
hydrometra  coincident  with  pregnancy.  In  that  case,  as  in  simple 
dropsy  of  the  womb,  we  should  prefer  the  puncture  through  the 
orifice  of  the  uterus,  as  recommended  by  Huermann,t  Zancf  and 
others.  However,  as  hydrometra  might  possibly  be  confounded 
with  true  pregnancy,  and  as  the  operation  might  be  followed  by 
fatal  consequences,  as  in  the  case  reported  by  Cruveilhier,§  too 
much  reserve  could  not  be  employed  in  the  use  of  a measure  never 

* Loder’s  Journal,  th.  iv.  st.  2.  p.  300 ; and  annal.  litt.  med.,  &c.,  t.  ii.  p.  290. 

f Abhandl.  von  den  Vornehemsten  chir.  op.,  th.  i.  nap.  5,  s.  186,  p.  410. 

i Darstell,  blut.  heilk.  operat.,  th.  iii.  abhand.  i.  289. 

§ Anat.  patholog.,  t.  i.  281. 


378 


HYDATIDS  OF  THE  WOMB. 


to  be  attempted  except  as  a last  resource.*  We  conclude  by  remark- 
ing, that  whatsoever  be  the  mode  by  which  the  liquid  may  have 
been  discharged,  we  should  provide  against  a relapse  by  the  prescrip- 
tion of  mild  detergent  injections,  by  keeping  the  cervix  open  for 
some  time  with  a small  gum-elastic  bougie,  and  by  combating  the 
general  as  well  as  the  local  symptoms  which  may  have  been  deemed 
the  causes  of  the  secretion.  ♦ 

OF  HYDATIDS  OF  THE  WOMB. 

Notwithstanding  the  existence  of  abdominal  hydatids  was  known 
to  the  highest  antiquity,  for  they  are  mentioned  by  Aretseus/f  Aetiusf 
was  the  first  among  the  ancients  to  speak  of  those  of  the  womb. 
These  morbid  productions,  classed  among  the  acephalocysts,  compose 
a .peculiar  class  of  vesicular  worms,  which,  though  well  described  as 
far  back  as  1805,  by  Laennec,  is  not  yet  admitted  by  the  German 
and  Italian  helminthologists. 

Two  species  of  hydatid  acephalocysts  have  been  admitted : 1. 
Acephalocysts  in  bunches,  or  pediculated  hydatids;  2.  Free  acepha- 
locysts; of  which  there  are  two  varieties:  1.  Hydatids  with  claws, 
and,  2d,  single  hydatids,  which  are  not  provided  with  claw  or  pedicle. 

The  pediculated  hydatids,  or  acephalocysts  in  bunches,  which  are 
found  only  in  the  womb,  and  which  are  at  present  regarded  as  trans- 
formed products  of  conception,  or  as  cysts  in  a peculiar  state,  are 
produced  not  only  in  certain  abortive  pregnancies,  but  occasionally 
also  in  true  pregnancy. 

The  pediculated  hydatid  is  a vesicle  of  a white  or  amber  colour, 
and  consists  of  a membranous  cyst,  filled  with  a transparent  limpid 
fluid,  that  is  sometimes  reddish  and  of  a gelatinous  consistence.  They 
float  in  a serous  liquor,  and  adhere  together  each  by  a very  delicate 
pedicle,  which  is  attached  to  a large  pedicle  after  the  manner  of  a 
bunch  of  grapes.  They  contract  adhesions  either  to  the  membranous 
bag  that  encloses  them,  or  to  the  walls  of  the  uterus,  to  the  umbilical 
cord,  to  the  placenta,  or  to  a fleshy  mole  which  they  are  sometimes 
observed  to  accompany. 

Hydatids  with  claws  are  of  a lenticular  shape  ; they  are  few, 
and  not  so  large  as  the  preceding ; they  develop  themselves  in  the 
vagina,  and  within  the  rugse  of  the  orifice  of  the  womb;  but  they 
are  always  found  there  in  considerable  numbers.  Generally  speak- 
ing, they  are  covered  with  an  extremely  thin  membrane,  and  adhere 
by  their  claw  to  the  point  upon  which  they  commenced  their  exist- 
ence. 

The  non-pediculated  acephalocyst,  without  the  claw,  has  been 
more  particularly  observed  in  the  ovaries,  and  in  the  Fallopian  tubes 

* In  order  to  avoid  the  puncture,  Sanctorius  invented  a sort  of  small-jointed  speculum, 
designed  to  open  the  mouth  of  the  womb,  evacuate  the  water,  and  admit  of  injections 
into  the  cavity.  (Comment  in  prim.  fen.  canon  Avicennae,  p.  608.) 

f Aretaeus  de  causis  et  signis  diuturn.  morb.,  lib.  iv.  cap.  i. 

i Med.  contractae  tetrabib.  iv.  serm.  iv.  cap.  79. 


HYDATIDS  OF  THE  WOMB. 


379 


when  dropsical.  Their  form  is  that  of  an  egg-shaped  sac,  of  a whit- 
ish mother-of-pearl  colour,  of  soft  and  fluctuating  consistence.  They 
are  always  free,  sometimes  single  and  isolated,  but  generally  nume- 
rous, and  contained  within  a common  cyst  filled  with  fluid,  in  which 
they  float  without  adhering  to  each  other.  The  cyst  that  serves  as 
their  envelope,  and  which  is  chronically  inflamed,  is  liable  to  become 
much  thickened,  gives  out  when  compressed  a sort  of  crepitating 
sound,  that  may  be  compared  to  the  sound  produced  by  squeezing 
a snow-ball  in  the  hands.. 

The  specific  gravity  of  the  free  hydatid  is  scarcely  greater  than  that 
of  water;  their  walls  are  thin  and  without  any  demonstrable  ves- 
sels; they  are  mostly  diaphanous,  but  sometimes  are  grayish,  opaque 
or  amber-coloured  ; the  texture  is  homogeneous  and  without  fibres; 
though  pretty  extensible,  it  resembles  half-cooked  white  of  eggs,  and 
separates  into  several  layers,  particularly  in  the  larger  hydatids. 

Whilst  we  admit  that  the  free  acephalocyst  of  the  non-gravid  womb 
may  be  possessed  of  vitality,  we  think,  on  the  other  hand,  that  the 
hydatid  vesicles,  resulting  from  morbid  transformation  of  the  pla- 
centa are  not  endowed  with  an  individual  independent  life,  but  like 
the  serous  cysts  receive  their  life  through  the  pedicle  that  sustains 
them.  A circumstance  that  militates  in  favour  of  this  opinion  is 
that  when  removed  from  the  situation  in  which  they  were  originally 
developed,  they  become  wilted  or  shriveled,  and  perish,  like  other 
serous  cysts,  as  soon  as  the  stalk  that  unites  them  with  the  surround- 
ing parts,  is  destroyed.  Instead  of  moving  in  water,  and  even  in 
the  paim  of  the  hand,  as  stated  by  Percy,*  the  placental  vesicles 
exhibit  merely  a sort  of  tremor  and  undulation  produced  by  a fluid 
contained  within  an  extremely  delicate  elastic  membrane. 

The  fluid  contained  in  the  bunch-like  hydatids,  is  perfectly  limpid  ; 
its  density  is  less  than  that  of  distilled  water ; it  turns  syrup  of  vio- 
lets green,  is  not  coagulable  by  heat  nor  alcohol,  which  proves  that 
it  is  not  albuminous,  and  is  similar  in  character  to  the  fluid  of  the  free 
acephalocysts. 

The  causes  of  hydatids  of  the  womb , and  other  female  genital 
organs,  are  but  little  understood  ; it  is  supposed,  however,  that  a 
lymphatic  temperament,  a chronic  leucorrhcea,  a suppression  of  the 
menses,  and  whatever  may  excite  or  keep  up  an  irritation  of  the 
sexual  organs,  may  contribute  to  the  production  of  the  disorder. 

The  symptoms  and  diagnosis  of  hyatids  are  very  obscure.  In 
the  commencement  of  the  disorder,  it  is  generally  confounded  with 
pregnancy  or  with  hydrometra,  nearly  all  the  external  characters 
of  which  it  exhibits,  except  that  the  distension  of  the  abdomen  does 
not  proceed  rapidly,  nor  to  so  great  a degree.  The  mere  presence  of 
hydatids  within  the  uterus  produces,  per  se,  very  trifling  conse- 
quences ; but  as  the  vesicles  increase  in  number  and  magnitude,  the 
hypogastric  region  becomes  flatulent,  soft  and  swollen.  Upon  Touch- 
ing, the  womb  is  found  to  be  much  larger  than  in  the  natural  state, 
but  its  orifice  continues  to  be  somewhat  open,  and  scarcely  altered 

* Jour,  de  Med.,  par  Corvisart,  Leroux,  and  Boyer,  Sept.  1811. 


380 


HYDATIDS  OF  THE  WOMB. 


either  as  to  its  shape,  or  position  in  the  pelvis.  Palpation  of  the 
hypogastrium  reveals  a globose,  compressible  and  indolent  tumour, 
which  has  an  obscure  fluctuation  when  compressed  from  above  in  a 
downward  direction.  In  most  cases,  the  tumour  yields  almost  all  the 
symptoms  of  pregnancy ; the  menses  are  suspended,  or  are  super- 
seded by  signs  of  flooding,  more  or  less,  which  recur  at  irregular 
periods  ; sometimes  the  breasts  swell,  a weight  in  the  pelvis  is  felt, 
with  very  severe  pains  in  the  uterus,  and  in  the  inguinal,  hypogastric 
and  lumbar  regions.  Sooner  or  later  the  woman,  after  having  been 
a prey  to  sufferings  and  losses  of  blood,  and  with  pains  as  violent  as 
those  of  child-birth,  suddenly  discharges  a quantity  of  vesicular 
hydatids,  which  come  away  altogether  or  at  several  different  times, 
and  accompanied  or  not  with  a foetus.  The  product  of  such  a la- 
bour is  what  is  called  an  hydatid  mole  or  a hydatid  dropsy,  or  vesi- 
cular dropsy.  Hydrometra  hydatica , vel  vesicularis. 

The  species  of  pregnancy  resulting  from  the  presence  of  pedicu- 
lated  hydatids  in  the  womb,  does  not,  in  general,  proceed  beyond  the 
sixth  or  the  seventh  month,  yet  the  expulsion  of  the  vesicles  has 
been  known  to  take  place  so  late  as  the  fourteenth  month.  To  assist 
the  escape  of  them,  it  has  been  necessary  to  use  injections  of  a mix- 
ture of  vinegar  and  salt  in  water,  and  in  some  instances  to  carry  the 
hand  into  the  womb  for  the  purpose  of  rupturing  the  sac  which  con- 
tains them.  After  such  a labour,  the  patient  commonly  experiences 
all  the  symptoms  that,  usually  follow  a regular  accouchement,  such  as 
discharge  of  lochia,  milk  fever,  swelled  breasts,  metro-peritonitis,  &c. 

When  the  discharge  of  the  hydatic  bunches  does  not  take  place 
soon  enough,  the  woman,  who  emaciates  rapidly,  is  liable  to  syncope 
and  frequent  floodings ; and  in  addition  to  these  symptoms,  there  are 
sometimes  conjoined  oedematous  swelling  of  the  limbs,  a bloated 
state  of  the  face,  hectic,  marasmus  and  death. 

Notwithstanding  the  vesicular  hydatid,  with  or  without  an  ac- 
companying embryo,  is  never  met  with  except  in  the  condition  of 
maternity,  the  real  acephalocyst  of  the  uterus  may  be  found  in  the 
virgin  state,  and  hydatids,  properly  so  called,  may  originate  in  the 
womb,  as  well  as  in  any  other  part  of  the  body.  The  celebrated 
Percy  relates  a case  that  removes  all  doubt  on  this  point,  and  in 
which  it  appears  that  he  succeeded,  by  undeniable  proofs,  in  pre- 
serving the  reputation  of  a canoness  of  twenty-six  years  of  age,  who 
had  been  subjected  to  the  most  unjust  suspicions. 

The  expulsion  of  the  acephalocyst  is  the  only  pathognomonic  sign 
of  uterine  hydatids.  After  the  womb  has  contracted,  the  patient  is 
to  be  treated  in  the  same  manner  as  after  a natural  delivery ; and 
when  all  signs  of  irritation  are  gone,  she  should  have  bitters,  tonics, 
chalybeates,  frictions,  and  aromatic  fumigations  to  the  genitalia,  for 
the  purpose  of  restoring  the  strength  of  the  constitution,  and  pre- 
venting the  formation  anew  of  the  hydatid  vesicles. 

Hydatids,  that  have  neither  pedicle  nor  unguicle,  and  that  are  only 
met  with  in  certain  cases  of  uterine  or  ovarian  dropsy,  require  no 
treatment  beyond  that  addressed  to  the  primary  affection.  The  signs 
of  them  are  also  similar,  for  their  presence  is  not  discovered  until 


CALCULUS  OF  THE  WOMB. 


381 


they  are  found  escaping  with  the  fluid,  or  obstructing  its  escape 
when  a puncture  has  been  made,  for  the  purpose  of  drawing  it  oft*. 
The  unguicular  hydatid,  which  is  the  most  rarely  met  with,  and  which 
forms  in  the  vagina  and  upon  the  neck  of  the  womb,  gives  rise  to  few 
symptoms ; when  discovered  by  means  of  the  speculum,  all  that  is 
necessary  is  to  detach  them,  and  prevent  their  reformation  by  atten- 
tion to  cleanliness,  and  particularly  by  using  vaginal  injections  of 
sulphur  water,  or  weak  decoctions  of  the  oak  or  pomegranate  bark. 

As  the  mode  in  which  the  hydatid  is  developed  and  reproduced  is 
as  yet  wholly  unknown,  we  feel  it  unnecessary  to  bring  forward  in 
this  place  the  opinions  of  Ruysch,  Albinus,  Morgagni,  Boerhaave,Val- 
lisnieri,  Morand,  Pallas,  Reuss,  Baer,  Percy,  Bremser,  Desormeaux, 
Bichat,  Laennec,  Soemmering,  Cloquet,  Breschet,  Cruveilhier,  Andral, 
Velpeau,  Raspail,  and  many  other  writers,  whom  it  is  not  requisite 
to  enumerate. 

OF  CALCULI  OF  THE  WOMB  AND  OTHER  GENITAL  PARTS. 

There  are  numerous  cases  that  show  clearly  that  calculous  concre- 
tions may  be  formed  within  the  cavity  of  the  womb.  Hippocrates 
speaks  of  the  servant  of  Dyseris,  of  Larissa,  who,  at  sixty  years  of 
age,  was  seized  with  pains  as  strong  as  the  pains  of  labour,  and  dis- 
charged a stone  as  large  as  a peson.  iEtius  also  makes  mention  of 
uterine  calculi,  and  recommends  that  they  should  be  extracted  by 
an  incision  of  the  cervix. 

Most  of  the  cases  reported  by  writers  of  the  last  few  centuries, 
have  been  collected  by  Louis,  in  a memoir  inscribed  among  the 
Mem.  de  VAcad.  de  Chirurgie.  They  contain  an  account  of  a girl 
sixty  years  of  age,  who  introduced  into  the  uterus,  [vagina  M]  a 
stone  the  size  of  a hen’s  egg,  without  being  much  incommoded  by  it. 
It  weighed  nine  drachms  and  a half.  Another  woman  had  a calcu- 
lus which  weighed  but  four  ounces,  and  which,  according  to  Louis, 
might  have  weighed  a pound,  had  the  material  not  been  so  porous. 
The  symptoms  felt  by  these  women  were  difficulty  in  walking,  and 
itching  of  the  vulva  and  internal  surface  of  the  thighs,  while,  in 
some  of  the  cases,  the  symptoms  were  still  more  slight  from  the 
smallness  of  the  calculi ; in  others,  the  patients  fell  victims  to  the 
exhaustion  arising  from  profuse  suppuration,  from  ulceration,  and  a 
local  degeneration,  produced  by  the  presence  of  calculus  in  the  womb. 

In  these  unfortunate  cases,  not  only  were  calculous  concretions  found 
after  death,  within  the  cavity  of  the  uterus,  but  the  body  of  the  viscus 
was  ascertained  to  have  been  converted  into  a substance  resembling 
dried  tallow.  The  same  author  says,  that  in  one  of  the  women  the 
parietes  of  the  womb  were  ossified,  and,  as  it  were,  moulded  round 
the  calculus.  He  also  adds,  citing  several  instances,  that  in  the  more 
fortunate  cases,  the  lithic  concretions  have  been  expelled  by  the  spon- 
taneous powers  of  the  womb. 

The  cases  collected  by  Louis,  and  those  published  by  Regnier  de 
Graff*,  Swammerdam,  Waither,  Van  Swieten,  Morand,  &c.,  leave  no 


382 


CALCULUS  OF  THE  WOMB. 


doubt  upon  the  subject  of  uterine  calculi.  One  of  the  most  curious 
cases  is  that  by  Bartholin,  who  mentions  a rough  black  calculus 
weighing  four  pounds,  taken  from  the  womb  of  a peasant  woman. 
Bromfield  also  speaks  of  concretions,  as  large  as  a child’s  head,  formed 
in  the  cavity.  Finally,  another  case,  quite  as  remarkable,  is  the  one 
reported  by  Ruysch,  (Ioc.  citat.,)  who  informs  us  that  he  removed 
from  the  womb  forty-two  calculi  of  different  sizes.  Were  it  not  for 
fear  of  trespassing  on  the  limits  assigned  for  this  work,  we  might 
quote  many  curious  examples  from  Marcellus  Donatus,*  J.  Schenck,t 
Theoph.  Bonnet, ± Steph.  Blancard,§  Michael  Morus, ||  J.  Lieutaud,H 
Joubert,**  M.  Nauche,tt  and  some  from  more  modern  writers. 

The  causes , under  the  operation  of  which  uterine  calculi  are 
formed,  are  still  imperfectly  known.  The  celebrated  Louis,  whose 
opinions  upon  the  subject  are  adopted  by  most  of  the  modern  patho- 
logists, thought  that  they  proceeded  from  the  aggregation  of  the  more 
solidifiable  portions  of  the  morbid  secretions  of  the  organ  in  the  same 
manner  as  urinary  and  biliary  calculi  are  formed  in  the  bladder  or 
the  biliary  cyst. 

Professor  Roux,  in  his  Melanges  de  Chirurgie,  emits  the  more 
probable  opinion  that  the  calculi  met  with  in  the  womb  are  pro- 
duced from  the  ossification  of  fibrous  tumours  developed  with  the 
organ,  or  in  the  substance  of  its  walls.  Pecquetlf  reports  two  in- 
stances that  favour  this  view  of  the  question,  and  adds,  adeo  ut  pro 
scirrhis  lapidescentibus  haberi  debeant  jrrsedicta  corpora.  Accord- 
ing to  M.  Roux,  fibrous  tumours,  while  undergoing  alteration,  be- 
come gradually  ossified, or  at  least,  are  invested  with  a covering,  more 
or  less  thick,  composed  of  the  saline  residuum  of  the  uterine  mucus. 
What  militates  in  favour  of  this  opinion  of  the  distinguished  surgeon 
of  the  Hotel-Dieu,  is  that  a chemical  analysis  of  one  of  these  calculi, 
proved  it  to  be  composed  of  a considerable  quantity  of  animal  mat- 
ter in  combination  with  salts  of  potassa,  soda  and  lime.§§  In  another 
calculus,  of  the  same  kind,  M.  Amusat  found  phosphate  of  lime  and 
gelatin. 

Concretions  of  the  womb  may  also  arise  from  small  concretes,  or 
fragments  of  an  embryo  that  may  have  passed  down  through  the 
Fallopian  tubes,  in  a case  of  extra-uterine  pregnancy.  They  may 
likewise  owe  their  existence  to  the  ossification  or  incrustation  of  a 
hardened  mole,  or  of  hydatids,  or  an  embryo,  or  foetus  that  had  per- 
ished at  an  early  stage  of  pregnancy  ; or,  in  fine,  to  foreign  bodies 
brought  into  the  womb,  which  have,  in  some  examples,  constituted 
the  nuclei  of  concretions.  Brugnatelli,  who  gives  the  chemical  ana- 

* De  histor.  medic,  mirabili.  lib.  iv.  cap.  30,  1586. 

j-  Observat.  med.  rar.  nov.  admirand.  monstr.  lib.  iv.,  1600. 

* Sepulchret.  seu  anatom,  practica.  lib.  iii.  sec.  24.  obs.  18,  1679. 

§ Anat.  prac.  ration  : sive  varior.  cadav.  morb.  &c.,obs.  74,  1688. 

H Acta  eruditor.  Lipsien.  August,  anno  1712. 

* Histor.  anatomic,  med.  sistens  numer.  cadaver,  human,  t.  i.  p.  340,  1767. 

**  Mem.  de  l’Acad.  de  Chirurg.,  t.  ii.  p.  140. 

ff  Maladies  des  femmes,  t.  i.  p.  214. 

t±  Exper.  Nov.  Anatom.  1651.  M.  Nauche  also  relates  a case  met  with  at  la  Sal- 
petriere  in  1799. 

§§  Revue  Medicale,  tom.  ii.  p.  301,  ann.  1824. 


CALCULUS  OF  THE  WOMB. 


383 


lysis  of  several  of  these  calculi,  says  that  one  of  them,  weighing 
about  two  ounces,  and  of  a peculiar  odour,  was  an  amorphous  mass 
with  an  irregular  surface,  and  of  a whitish  colour.  Being  insoluble 
in  water,  it  was  broken  by  a blow  with  a hammer,  and  no  little  sur- 
prise was  felt  to  find  within  it  part  of  the  tibia  of  a chicken.  Probably 
the  whole  bone  had  been  introduced  under  an  attack  of  erotomania, 
and  had  served  as  the  means  of  a shameful  and  disgusting  manoeuvre.* 
The  symptoms  of  calculus  in  the  womb  are  either  null,  or,  in  some 
of  the  cases,  very  obscure — however,  the  patient  generally  suffers 
from  dull  or  pungent  pain  in  the  hypogaster,  and  a feeling  of  weight 
in  the  back  and  groins.  To  these  symptoms  are  added  an  intolerable 
pruritus  of  the  vulva,  and  mucous,  purulent  and  sanguineous  dis- 
charges from  the  vagina.  The  pains  increase,  or  return  at  intervals, 
and  sometimes  become  so  acute  that  they  end  in  the  spontaneous 
expulsion  of  the  calculous  matter.  The  presence  of  these  foreign 
bodies  interferes  with  the  urinary  and  alvine  excretions:  and  when 
they  are  situated  near  the  neck,  and  especially  when  the  os  tincse 

* In  No.  3.,  Jan.  6,  1838,  of  la  Lancette  Fran5aise,  we  read  a very  curious  case 
which  we  quote  as  related  in  that  excellent  journal,  from  an  English  periodical. 

“ A woman,  habitually  subject  to  suppression  of  urine,  was  seized,  on  the  tenth 
of  June,  with  total  suppression  of  urine.  A physician  being  called  in,  she  was 
relieved  by  the  catheter.  The  suppression  continued  for  two  months,  so  that  the 
patient  could  not  empty  her  bladder,  save  by  the  catheter,  which  the  physician  intro- 
duced twice  each  day.  At  the  end  of  this  period,  being  unable  to  defray  the  expense, 
she  introduced  the  catheter  herself,  making  use,  for  the  purpose,  of  the  stem  of  a 
tobacco  pipe.  She  was  successful  for  some  time,  but  at  length  the  tobacco  pipe 
broke  in  the  urethra,  and  her  attempts  to  extract  it,  forced  it  into  the  bladder,  where 
it  was  lost. 

“The  accident  happened  on  the  fifteenth  September.  The  woman  now  procured 
a metallic  catheter,  and  continued  the  use  of  it,  having  forgotten,  as  it  were,  the 
foreign  body  in  the  bladder,  until  the  twenty-seventh  April.  At  that  time  she  was 
seized  with  pains,  like  labour  pains.  M.  H.  Martin,  who  was  called  in,  examined 
the  parts,  and  found  the  pipe-stem  in  the  cavity  of  the  womb.  One  end  of  it  was 
projecting  from  the  os  uteri,  and  was  so  strongly  grasped  by  the  organ,  that  he  was, 
for  its  extraction,  obliged  to  make  use  of  a pair  of  pincers,  and  use  considerable 
force  for  the  purpose.  The  extraction  was  quite  a difficult  task,  for  the  pipe-stem 
broke  several  times  while  he  was  doing  it. 

“ Three  years  afterwards  the  woman  died  with  phthisis,  and  her  genito-urinary 
organs  presented  the  following  appearance  upon  dissection: 

“The  bladder  was  thickened,  and  contained  no  foreign  body.  At  its  left  side  not 
far  from  the  orifice,  was  a patch,  the  size  of  a sixpence,  much  softer  than  the  rest  of 
the  mucous  surface,  and  which  tore  upon  the  lightest  touch  of  the  fingers.  ‘I  con- 
cluded,’ says  the  author,  ‘ that  it  was  here  the  foreign  body  passed  from  the  bladder 
into  the  vagina,  and  thence  into  the  os  tincse.  It  seemed  to  me,  indeed,  impossible 
that  it  should  have  passed  directly  from  the  bladder  into  the  womb,  for  no  cicatrix, 
nor  way  of  communication  was  discovered  betwixt  these  two  organs.’ 

“ The  broken  pipe-stem  was  three  inches  in  length,  and  much  incrusted  with  cal- 
careous matter.” — East  London  Lying-in  Institute. 

This  case  is  very  curious,  from  the  rarity  of  the  circumstances  accompanying  it. 
It  is  true,  that  cases  are  known  of  inorganic  bodies  found  within  the  womb,  such  as 
calculi,  that  have  given  rise  to  strange  symptoms,  ( Sabatier , Mem.  de  P Acad,  de  Chi- 
rurg .) ; cases  also  are  known  of  urinary  calculi  that  had  passed  into  the  vagina,  but 
none  of  them  can  be  compared  with  this  one. 

We  cannot  refrain,  however,  from  remarking,  that  it  is  doubtful  whelher  the  pass- 
age of  the  pipe-stem  took  place  by  the  route  indicated  by  the  English  surgeon.  We 
should  rather  be  inclined  to  think,  that  the  woman,  making  a mistake  in  using  the 
catheter,  passed  it  into  the  womb,  and  not  into  the  bladder.  The  softened  patch  in 
the  bladder,  was  perhaps  the  cause  of  the  suppression  of  urine  in  her  case. 


384 


CALCULUS  OF  THE  WOMB. 


is  partially  dilated,  they  can  be  touched,  either  with  the  finger,  or  with 
a sound  or  catheter. 

The  signs  above  pointed  out  are  far  from  being  always  present, 
for  the  calculus  may  give  rise  to  no  symptom  at  all,  and  be  disco- 
vered only  after  death.  They  are  in  general  found  only  in  persons 
at  a somewhat  advanced  age,  yet  they  have  also  been  met  with  in 
young  persons;  in  girls  of  twenty-nine  years,  of  fifteen  years,  and 
even  in  a little  girl  eight  years  old,  who  fell  a victim  to  suppression 
of  urine.  At  the  post-mortem  examination,  the  bladder  was  quite 
sound,  but  a calculus  of  a white  colour,  and  of  the  size  of  a large 
pigeon’s  egg,  was  found  within  the  uterus.  Rammazini*  informs  us 
that  he  also  saw  a spongy  calculus  extracted  from  the  uterus  of  a 
little  girl. 

The  treatment  of  uterine  calculus  varies  according  to  circum- 
stances, as  to  their  form,  size  and  situation  in  the  womb.  As  long 
as  the  calculus  does  not  interfere  with  the  general  health,  and  its 
existence  is  only  betrayed  by  the  discharge  of  some  fragments,  we 
should  confine  ourselves  to  the  administration  of  such  measures  as 
are  calculated  to  favour  its  entire  expulsion,  such  as  baths  and  emol- 
lient and  narcotic  injections. 

In  case  of  any  serious  symptoms  arising,  and  with  the  cervix  uteri 
large  and  readily  dilatable,  the  immediate  extraction  of  the  calculus 
should  be  attempted  with  a pair  of  long,  narrow  pincers;  or  use 
might  be  made  of  what  is  called  Hunter’s  forceps,  or  what  is  still 
better,  the  three-pronged  forceps  of  the  lithontriptic  set.  Should  the 
os  uteri  not  admit  of  the  introduction  of  instruments,  it  should  be 
enlarged  by  several  incisions,  according  to  the  plan  practised  by 
Aetius  more  than  1300  years  ago,  after  which  the  operation  might 
be  very  easily  concluded.  If  a calculus  should  be  found  to  adhere, 
it  should,  if  possible,  be  detached,  by  carefully  moving  it  in  different 
directions.  In  fine,  where  the  stone  is  moulded  by  the  shape  of  the 
cavity  of  the  womb,  and  especially  where  its  surface  is  rough  and 
uneven,  all  attempts  at  exti'action  would  prove  not  only  nugatory, 
but  would  lead  to  fatal  lacerations.  Under  such  circumstances,  re- 
garded by  all  practitioners  as  beyond  the  reach  of  art,  we  imagine  that 
recourse  might  be  advantageously  had  to  lithotripsy  in  order  to  reduce 
the  calculus  to  powder,  which  might  be  done  with  less  danger  than 
if  the  stone  were  in  the  urinary  bladder.  We  shall  conclude  by  ob- 
serving that  no  attempt  to  perforin  such  operations  as  have  been 
described  should  ever  be  made  except  under  an  absolute  and  certain 
knowledge  of  the  existence  of  a calculus  in  the  uterine  cavity.  All 
doubt  on  the  subject  may  be  dissipated  by  the  use  of  a sound,  which, 
by  the  shock  and  friction  of  its  point,  enables  us  to  appreciate  the 
consistence  and  hardness  of  the  concretion,  and  even  to  break  off 
fragments  of  it.  Such  bits  of  calculus,  when  brought  away,  would 
furnish  clear  evidence  of  the  case,  could  we  make  sure  that  they  did 
not  come  from  the  urethra  or  had  not  been  formed  in  the  vagina  by 
some  vesical  fistula. 


Ephemerides  Natur.  Curios.,  sec.  i.  75.  Num.  4,  5.  Obs.  65. 


POLYPUS  OF  THE  WOMB. 


385 


Small  concretions  formed  in  the  substance  of  the  womb  require 
no  treatment ; and  they  give  rise,  moreover,  to  no  symptoms,  and 
cannot  be  ascertained  during  the  life  of  the  patient  by  any  appreci- 
able sign.  Those  that  are  formed  in  the  vagina,  look  like  red  gravel, 
and  are  composed  of  uric  acid ; or,  they  may  be  of  larger  size  and 
of  a chalky  appearance,  and  a whitish  colour,  in  which  case  they 
will  be  found  to  consist  of  a phosphate  of  lime  and  an  ammoniaco- 
magnesian  base.  Vaginal  calculi  of  this  kind  may  sometimes  be 
found  of  great  magnitude.  Koeler*  met  with  live  such,  weighing 
about  seven  ounces,  in  the  vagina  of  a woman  labouring  under  prolap- 
sus uteri.  These  concretions  are  chiefly  met  with  in  cases  of  displace- 
ment of  the  organ,  and  have  been  well  described  by  Graaf,  Lank- 
risch,  and  Bouvet.  Foreign  bodies,  allowed  to  remain  and  become 
altered  in  the  womb,  are  frequent  causes  of  calculus.  Their  nucleus 
is  commonly  portions  of  sponge,  or  of  cork  or  wax  pessaries.  Hoff- 
man, Walter  and  M.  Breschet,  and  other  authors,  cite  examples  of 
this  kind. 

These  vaginal  concretions,  which  in  themselves  considered  are  not 
very  dangerous,  but  often  exceedingly,  inconvenient,  may  be  pro- 
duced either  by  a morbid  secretion  of  the  procident  womb  or  by 
infiltration  of  urine.  They  form  like  the  calculous  incrustations  on 
pessaries  left  for  a long  time  in  the  vagina.  They  are  readily  disco- 
vered by  the  finger,  or  by  means  of  a sound  passed  into  the  vagina. 
As  soon  as  they  are  discovered,  they  should  be  removed  with  proper 
pincers  or  forceps,  after  which  the  patient  should  be  directed  to  use 
vaginal  injections,  and  frequent  baths,  to  prevent  their  formation 
again.  Lastly,  calculous  concretions,  which  certain  authors,  among 
whom  may  be  named  Stoeller  and  Soemmering,  say  they  have  found 
in  the  surface  of  the  labia  and  nymphae,  may  be  easily  recognized 
by  the  simple  inspection  of  the  parts,  and  it  would  always  be  easy 
to  remove  them  at  once. 

OF  POLYPUS  OF  THE  WOMB  AND  VAGINA. 

It  is  difficult  accurately  to  define  a polypus  of  the  womb,  for  several 
dissimilar  tumours,  having  nothing  in  common  except  their  situation, 
have  been  comprised  under  the  appellation.  In  general,  by  the  term 
polypus  of  the  womb,  is  now  designated  any  tumour,  any  excre- 
scence or  preternatural  tumour,  rising  by  a base  or  pedicle,  whether 
small  or  large,  from  the  mucous  membrane  of  the  neck  or  body  of 
the  organ. 

Polypus  uteri,  though  not  well  described  before  the  eighteenth 
century,  was  nevertheless  known  to  the  highest  antiquity  ; and 
while  Hippocrates,  Celsus  and  Galen  make  no  mention  of  it,  Philo- 
tenus,t  who  lived  antecedent  to  the  two  latter  authors,  indicates  with 
sufficient  clearness  the  progress  of  the  uterine  polypus.  If  we  may 
judge  from  the  few  words  he  has  uttered  ou  the  subject  of  the  treat- 

* Diet,  de  Med.,  t.  iv.  art.  calcul. 

t Harmonia  Gynaeciorum,  p.  138,  1566,  and  Peyrilhe,  p.  115,  1780. 

25 


386 


POLYPUS  OF  THE  WOMB. 


ment,  we  may  infer  that  the  method  he  employed  was  to  tear  them 
away,  and  to  excise  them  with  instruments.  Moschion,  in  his 
Treatise,  ( de  mul.  affectibus ,)  which  was  published  by  Spachius, 
in  1566,  was  the  first  to  give  the  name  pulps  or  polypus  to  the 
pediculated  fibrous  tumours  of  the  uterus  ; but  his  words  show  that 
his  notions  on  their  nature  were  not  any  dearer  than  those  enter- 
tained by  his  predecessors.  We  must  come  down  to  the  time  of 
Guillemeau,  who  was  the  pupil  of  Ambrose  Pare,  to  find  a pretty 
clear  description  of  the  polypus ; but  to  Levret*  belongs  the  honour 
of  having,  by  the  study  of  different  cases,  dissipated  the  obscurity 
that  covered  the  anatomy,  the  diagnosis,  and  treatment  of  polypous 
tumours  This  subject,  which  had,  in  the  last  century,  been  more  or 
less  illustrated  by  Lamzweerdet,  Schacher,f  Kaltschmitt,§  and  Her- 
biniaux,||  requires  scarcely  any  further  development,  since  the  la- 
bours of  Dessault,^  of  Bichat,**  of  Denman, tt  of  Boyle,±±  of  Mess. 
Roux,§§  Grainger, mi  Mayer, Breschet,***  Hervez  de  Chegoin,ttt 
Simson,tf±  Dupuytren,§§§  Malgaigne,||||||  Gerdy,1HfH  Duges,**** 
Blandin,tttt  and  others  too  tedious  to  mention. 

We  shall  say  but  little  as  to  the  pathological  anatomy  of  the 
polypous  and  fibrous  bodies  of  the  uterus,  because  we  have  nothing 
new  to  offer  upon  the  subject,  and  also,  because,  to  set  forth  all  the 
various  opinions  of  authors  concerning  them,  would  extend  the 
notice  too  far. 

Levret  distinguished  two  species  of  polypus,  and  since  his  day, 
most  of  the  writers  on  the  subject  have  increased  the  division,  and 
embraced  within  it  the  white  vesicular  polypus,  the  red  vesicular 
polypus,  the  fibrous  polypus,  and  also  the  sarcomatous  polypus, 
which  is  of  a deep  red  colour,  an  irregular  shape  and  a some- 
what botryoidal  tuberculated  surface.  At  the  commencement  of 
their  growth,  they  are  indolent,  but  they  soon  become  the  seats  of 
lancinating  pain,  rapidly  assume  a cancerous  character,  and  excrete 
from  the  surface  a bloody  discharge,  which  is  often  found  to  be  con- 

* Obs.  sur  la  cure  radicale  de  plusieurs  polypes  de  la  matrice,  1740. 

f Hist  naturalis  mal.  uteri.,  Lugd.,  in  12mo.,  1686. 

4 Programma  de  polypis,  &c.,  Leips.,  1721. 

§ De  mola  scirrhosa  in  utero  extirp.,  Jena,  1734. 

H Traite  des  acc.  labor,  et  sur  les  polypes  de  la  matrice,  t.  ii.,  1782. 

^ CEuvres  chirurg.,  t.  ii. 

**  Mem.  de  la  soc.  med.  d’emulation.t.  ii. 

•ff  Plates  of  a polypus,  &c.,  of  the  uterus,  1801. 

44  Diet,  des  Sci.  Med. 

§§  Memoires  sur  les  polypes.  Melanges  de  chir. 

||  ||  Med.  and  Surgical  remarks,  &c.,  method  of  removing  polypi  from  the  ute- 
rus, 1815. 

m De  polypis  uteri.  Berolini,  1821. 

***  Diet,  de  Med.,  in  21  vols.,  vol.  i.,  17. 

Iff  Journal  General  de  Medicine,  Oct.  1817.  Remarques  sur  la  disp.  anat.  des 
polypes  de  la  matrice. 

444  De  polypis  uteri.  Berolini,  1828. 

§§§  Clinique  chir.  Le5ons  orales,  t.  iii. 

Him  Des  polypes  uterins.  These  d’aggregation  en  chir., in  4o.  1832, and  in  8vo.l833. 

Des  polypes  et  de  leur  traitement,  1833. 

****  Mal.  de  l’uterus,  t.  i.,  1833. 

-j-f-j-j-  Diet,  de  Med.,  et  ehir.  pratiques,  t.  xiii.,  1835. 


POLYPUS  OF  THE  WOMB. 


387 


stant.  M.  Malgaigne  ( loc . citat.)  makes  five  divisions : 1,  the  vesicu- 
lar; 2,  the  cellulo-vascular ; 3,  the  polypus  from  hypertrophy;  4,  the 
moliform,  and  5,  the  fibrous  polypus.  Inasmuch  as  we  look  upon 
some  of  these  varieties  of  polypus  as  being  merely  the  fungous  vege- 
tations of  the  haematode  cancer  of  the  womb,  or  the  carcinomatous 
degeneratibn  of  a fibrous  polypus,  we  shall  confine  our  observations 
to  the  two  kinds  most  commonly  met  with,  videl. : the  cellulo-vascu- 
lar or  soft  polypus,  and  the  fibrous  or  hard  polypus,  which  are  sub- 
divided into  pediculated,  and  sessile  or  non-pediculated. 

The  cellulo-vascular  polypus  is  commonly  found  upon  the  os 
tincse,  and  within  the  canal  of  the  cervix  uteri.  In  general,  it  is  not 
large,  is  readily  compressible,  indolent,  light,  of  soft  consistence  ; its 
colour  is  white,  or  more  or  less  deep  rose  or  red-tinted,  according  to  the 
number  of  its  blood-vessels.  These  polypi  may  be  simple  or  multi- 
ple, immovable,  with  a broad  base,  though  for  the  most  part  they  are 
attached  by  means  of  a pedicle,  of  various  lengths  in  different  spe- 
cimens. These  polypi,  which  are  rare  and  not  very  dangerous, 
incommode  the  patient  only  by  causing  a very  abundant  sero-mucous 
discharge. 

Where  the  cellulo-vascular  polypus  attached  to  the  os  tincm  is  of 
small  size,  it  is  often  a difficult  matter  to  detect  it  by  the  touch,  for  it 
flees  before  the  contact  of  the  finger,  which  flattens  or  glues  it  to  the 
side  of  the  womb.  The  best  way  here  is  to  move  the  finger  in  a 
transverse  direction  across  both  the  inner  and  outer  surface  of  the 
uterus,  by  doing  which  we  shall  discover  one  or  more  tumours,  soft, 
almost  undulating,  and  somewhat  salient, that  maybe  moved  in  any 
direction. 

In  the  Bulletin  des  Sciences  Medicates  for  October,  1827,  Profes- 
sor Dopuytren  points  out  the  following  characters  : 

“ The  cellular  and  vascular  polypi  presenting  symptoms  analogous 
to  those  of  cancer  of  the  cervix  uteri,  escape,  by  their  minuteness, 
the  most  careful  search.  They  force  both  physician  and  patient  to 
despair.  The  discharges,  whether  white  or  red,  are  commonly 
attended  with  a sense  of  fatigue  in  the  loins,  dragging  feelings  in  the 
groins  and  pressure  at  the  fundament;  there  is  both  physical  and 
moral  exhaustion,  which  is  promptly  induced  by  the  loss  of  blood, 
and  the  continued  pain.  This  bleeding,  and  still  more  the  white  dis- 
charge, are  easily  brought  on  by  the  slightest  touch,  by  coitus,  by  the 
approach  of  the  menses,  and  they  are  easily  detected,  either  by  the 
touch  or  by  the  use  of  the  speculum.  Let  the  finger  be  conducted 
to  the  os  tincae,  and  within  its  circuit  we  shall  find  one,  two  or  more 
small,  elongated  pediculated  bodies,  implanted  in  the  lower  part  of 
the  canal  of  the  cervix ; they  vary  in  size  from  that  of  a pea  to  that 
of  a lddney-bean;  they  bleed  at  the  lightest  touch;  and  if,  instead  of 
trusting  to  the  touch  alone,  we  examine  them  with  the  speculum,  we 
find  the  neck  and  the  mouth  of  the  womb  red,  dilated,  and  filled 
with  little  reddish  bodies  elongated,  pediculated  and  implanted  upon 
the  neck.  There  is  no  disease  with  which  this  malady  has  not  been 
confounded.” 

The  treatment  of  polypous  tumours  of  this  sort  consists  in  eradi- 


3SS 


POLYPUS  OF  THE  WOMB. 


eating  them  by  a mixed  process  of  avulsion  and  torsion.  For  this  end 
the  parts  should  be  exposed  by  means  of  our  jointed  speculum,  which 
enables  us  to  dilate  the  vagina  in  every  dimension,  and  that  chiefly 
at  the  part  on  which  we  have  to  operate ; and  then  after  cleans- 
ing the  polypous  tumour  with  a plumaseau  of  charpie,  held  in  a 
long  forceps,  or  on  the  handle  of  our  port-caustic,  it  should  be  seized 
with  a proper  pair  of  forceps  so  as  to  twist  it  off  and  remove  it,  taking 
care  to  carry  the  open  gripe  of  the  instrument  to  the  very  root  of  the 
pedicle,  so  as  to  be  sure  of  effecting  a complete  eradication  of  it.  We 
may  be  sure  of  having  effected  this  object,  if  we  find  with  the  finger 
a pit  or  depression  at  the  spot  whence  the  pedicle  sprung.  The 
hypertrophy  and  the  oedema  of  the  neck  of  the  womb  which  fre- 
quently accompany  the  cellulo-vascular  polypus,  may  be  subse- 
quently treated  by  the  measures  pointed  out  in  our  remarks  upon 
those  affections,  while  the  simple  ulcers  caused  by  the  avulsion  of  the 
pedicles,  should  be  managed  by  the  use  of  antiphlogistics,  rest,  and 
cauterization. 

The  pediculated  fibrous  polypus  is  ordinarily  of  a rounded  form, 
as  long  as  it  continues  to  inhabit  the  cavity  of  the  womb,  but  as  soon 
as  it  escapes  from  that  organ,  it  becomes  pear-shaped,  with  the  large 
end  downwards.  The  tumour,  which  is  at  first  small,  increases  m 
some  instances  rapidly,  and  in  others  remains  stationary,  after  ac- 
quiring certain  dimensions.  According  to  Boyer,  some  of  them  then 
diminish  in  size  and  almost  wholly  disappear,  by  the  powers  of 
nature  merely.  These  tumours  are  connected  with  the  womb,  by  a 
pedicle,  which  differs  in  different  specimens  as  to  its  point  of  attach- 
ment, its  size  and  its  organization. 

Indeed,  the  pedicle  which  adheres  to  the  inner  surface  or  cavity  of 
the  womb,  or  the  canal  of  the  cerevix,  or  to  one  of  the  lips  of  the  os 
tincae,  may  be  thin,  slender,  long,  and  weak,  or  hard,  thick,  short  and 
strong. 

The  interior  texture  of  the  fibrous  polypus  uteri,  is  very  similar  to 
that  of  the  organ  itself,  that  is  to  say,  it  is  dense,  firm,  strong,  and  exhi- 
bits the  same  inextricable  decussation  of  fibres.  Vessels  are  found  in 
it  which  are  not  always  very  apparent,  though  their  existence  is  indu- 
bitable, from  the  red  colour,  and  more  especially  from  the  growth 
of  the  tumour.  When  cut  into,  it  creaks  under  the  knife,  and  the 
sensation  it  gives  rise  to  is  like  that  produced  by  cutting  the  sub- 
stance of  the  uterus.  Along  with  the  reddish  tint  we  have  mentioned, 
is  conjoined  a slightly  yellowish  colour,  which  is  the  paler,  as  the 
density  is  greater.  Though  the  existence  of  nerves  in  these  bodies 
cannot  be  demonstrated,  their  presence  is  proved  by  the  pain  result- 
ing from  the  constriction  of  their  pedicles. 

[I  cannot  agree  with  Mr.  C.  in  this  view.  Such  a tumour  is  insensible 
to  pressure,  though  the  stricture  of  it  may  disturb  or  distract  the  sensitive 
parts  upon  which  it  sits.  A surer  proof  of  its  possessing  nerve  power  is  the 
fact  of  its  having  power  to  grow.  The  tumour  is  organized — not  crystal- 
lized, as  by  simple  aggregation  of  its  molecules,  but  by  regular  nutrition — 


POLYPUS  OP  THE  WOMB. 


389 


which  cannot  be  hypothecated  of  any  non-nervous  structure.  The  simple 
fact  that  it  has  blood-vessels  shows  that  nerve  filaments  must  accompany 
those  vessels — both  the  vessels  and  the  tumour  would  perish  without  nerves. 
As  to  the  pale  yellowish  red  colour  of  this  fibrous  polypus,  I beg  leave  to  say 
that  I saw  one  discharged  by  violent  labour  pains  from  the  uterus  of  a negro 
woman,  at  Augusta,  in  the  State  of  Georgia,  in  1812.  It  was  as  large  as 
the  head  of  a full-grown  foetus,  and  had  been  attached  to  the  fundus  uteri  by 
a pedicle  as  large  as  the  little  finger.  The  uterine  contractions,  after  dilating 
the  os  uteri  and  expelling  the  mass  into  the  vagina,  with  prodigious  pain, 
forced  the  tumour  through  the  vulva,  when  the  pedicle  parted,  and  the 
woman  was  freed  from  a long  trouble.  The  surface  of  that  tumour  was  of 
a blackish  soot-colour,  and  very  rough — it  was  hard  and  elastic — and  upon 
laying  it  open  with  a scalpel,  was  found  to  consist  of  spherical  and  oval  cells 
or  loculi,  some  an  inch  in  diameter  with  an  infinity  of  smaller  ones;  the 
cells  were  filled  with  a viscous  fluid  resembling  bloody  synovia.  I removed 
one  in  1843,  which  was  of  a whitish  colour,  faintly  tinged  with  brown.  It 
had  occasioned  enormous  floodings  and  the  most  distressing  anemia  trauma- 
tica, for  six  or  eight  years — in  that  case  there  were  no  cells  in  the  substance 
of  the  tumour. — M.] 

Fibrous  polypi,  developed  in  the  sub-mucous  tissue  of  the  uterus, 
are  covered  with  the  mucous  membrane  of  that  organ  which  extends 
with  the  growth  of  the  tumour,  and  composes,  in  conjunction  with 
the  blood-vessels,  and  some  fibro-cellular  tela,  which  it  invests,  the 
pedicle  or  stalk  by  which  the  morbid  production  is  attached.  This 
pedicle  grows  smaller,  in  some  instances,  to  such  a degree  as  to  break 
olf,  and  permit  in  that  way  a spontaneous  cure,  as  in  instances  cited 
by  Mauriceau,  Ruysch,  Hoffman,  Levret,  Dupuytren,  and  Hervez 
de  Ch6goin.  It  occasionally  happens,  on  the  other  hand,  that  the 
pedicle  is  hard,  solid,  and  does  not  stretch  at  all,  or  it  even  accpiires 
greater  and  greater  thickness  as  the  tumour  enlarges.  Polypi  have 
been  met  with,  whose  pedicle  had  grown  sufficiently  to  measure 
above  four  inches  in  circumference. 

Though  the  shape  of  the  pediculated  fibrous  tumour  is  commonly 
ovoidal  or  pyriform,  they  are  sometimes  botryoidal,  flattened,  angu- 
lar, cylindroidal,  strangulated,  irregular,  and  divided  into  lobes. 
They  vary  in  size  from  that  of  a lentil  (Bayle)  to  that  of  a man’s 
head.  M.  Marjolin  mentioned  in  his  lectures,  that  he  had  seen  a 
polypus  uteri  as  large  as  the  head  of  an  adult.  The  tumour,  which 
had  inverted  the  womb  upon  descending  into  the  vagina,  compressed 
the  bladder  and  the  rectum  violently.  After  fruitless  endeavours  to 
extract  it  with  the  forceps,  it  was  proposed  to  make  a section  of  the 
symphysis,  which  merely  rendered  the  tumour  more  salient ; and  it 
was  not  extracted  until  after  the  woman’s  death,  when  it  was  re- 
moved through  the  hypogastrium.  The  old  Journal  de  Medecine , 
tom.  63,  speaks  of  a polypus  weighing  ten  pounds  and  a half,  and 
eighteen  inches  in  circumference  at  the  base,  and  thirteen  inches  long. 
This  polypus,  whose  proper  tissue  consisted  of  fleshy  fibres  running 
in  various  directions,  was  inserted  upon  the  os  tincae.  In  fine,  M. 


390 


POLYPUS  OF  THE  WOMB. 


Gaultier  de  Claubry,  sen.,  has  published  an  account  of  a polypus 
weighing  thirty-nine  pounds,  and  thirty-five  inches  in  its  vertical  cir- 
cumference by  twenty-nine  inches  in  horizontal  circumference.  These 
large  polypous  masses  distend  the  uterus  almost  as  much  as  a foetus  at 
term,  and  produce  modifications,  analogous  to  those  of  pregnancy, 
not  in  the  womb  only,  but  in  the  breasts,  and,  indeed,  throughout  the 
entire  constitution  of  the  female. 

[M.  de  Claubry’s  polypus,  of  thirty-nine  pounds  weight,  could  not  pos- 
sibly have  been  contained  within  the  womb,  or  the  womb  and  vagina  toge- 
ther. The  comparison  with  the  foetus  at  term  is  useless;  the  heaviest  foetus 
I have  seen  weighed  thirteen  and  a half  pounds.  Twins,  born  under  my 
care,  weighed  eight  and  a half  pounds  respectively,  aud  triplets,  carefully 
weighed,  furnished  a sum  of  twenty-one  pounds  weight.  But  these  are 
far  short  of  thirty-nine  pounds.  Here  we  must  suppose  M.  de  C.’s  case  to 
have  been  extra-uterine  in  its  location. — M.^] 

Certain  kinds  of  polypi,  instead  of  forming  a compact  fibrous 
mass,  exhibit  cavities  in  the  interior,  giving  rise  to  so  great  a resem- 
blance to  the  womb  itself,  that  many  limes  a surgeon,  who  had 
extirpated  a polypus,  has  supposed  himself  to  have  effected  the  com- 
plete ablation  of  the  womb.  Boudon,  Maune,  and  Collin,  not  only 
fell  into  this  mistake,  but  what  is  still  more  extraordinary,  affirmed 
that  their  patients  again  became  pregnant  after  the  operations.  Such 
a mistake  may  be  readiiy  conceived  of,  when  it  is  a fact,  that  in  the 
year  1823,  and  in  the  hospital  St.  Louis,  two  practitioners,  so  distin- 
guished as  Mess.  Richerand  and  J.  Cloquet,  having  extirpated  a hol- 
low polypus,  supposed  they  had  removed  the  entire  uterus,  which, 
however,  was  found  in  its  proper  place  upon  the  death  of  the  woman, 
which  took  place  subsequently.  There  is  yet  another  kind  of  hol- 
low polypus,  that  must  not  be  confounded  with  those'  we  have  men- 
tioned ; we  speak  of  polypi,  whose  interior  cavity  contains  cerebri- 
form  matter,  fungous  substance,  effused  blood,  or  any  of  the  products 
of  the  cancerous  degeneration. 

The  polypi  that  are  most  liable  to  undergo  this  pathological  trans- 
formation, are  those  in  which  there  is  a predominance  of  cellular 
tissue.  Those,  on  the  other  hand,  in  which  the  fibrous  exceeds  the 
cellular  element,  only  degenerate  into  an  osseous  state,  or,  at  least,  if 
they  do  become  scirrhous  or  cancerous,  the  transformation  proceeds 
from  the  circumference  towards  the  centre,  because,  in  that  case,  it 
does  not  depend  upon  the  reaction  of  the  different  elements  upon 
each  other,  but  upon  an  inflammation  of  the  womb,  and  especially 
of  the  internal  membrane  of  it.  Inasmuch  as  it  appears,  from  a 
remark  made  by  Dupuytren,  [Med.  Opera/,  de  Sabatier , t.  iv.,  337,) 
that  the  external  layers  of  polypi  are  the  parts  that  first  pass  into  the 
cancerous  condition,  and  that  the  body,  or  at  least  the  pedicle  of  the 
tumour,  is  almost  always  found  in  a sound  state ; we  may  attack 
them,  with  some  hopes  of  success,  even  where  they  seem  to  be  already 
somewhat  advanced  into  a condition  of  cancerous  degeneration. 

Professor  Cruveilhier  speaks  of  another  kind  of  hollow  polypus,  of 
which  he  has  met  with  several  specimens.  They  result  from  a true 


POLYPUS  OF  THE  WOMB. 


391 


hypertrophy  of  the  proper  tissue  of  the  uterus,  and  contain  certain 
cavities  similar  to  the  ^uterine  sinuses,  and  which  are  commonly 
found  full  of  black  grumous  blood. 

Inasmuch  as  the  pathologists  are  not  agreed  as  to  the  various  sorts 
of  pediculated  polypi,  we  shall  dispense  with  any  remarks  upon  the 
subject,  particularly  as  no  good  could  arise  from  them  in  a practical 
point  of  view. 

The  non-pediculated  fibrous  polypus,  or  fibrous  tumour  of  the 
uterus,  is  a tumour  of  the  same  internal  texture  as  the  pediculated 
kind,  but  differs  in  respect  that  it  grows  without  any  pedicle,  and 
springs  either  from  beneath  the  peritoneal  coat  or  in  the  substance  of 
the  uterine  texture.  The  latter,  though  enclosed  within  the  substance 
of  the  womb,  are  not  connected  with  it  by  any  continuity  of  tissue, 
but,  being  produced  de  novo,  they  are  circumscribed  and  enveloped 
in  a layer  of  cellular  tela,  compact  enough  to  make  them  appear  as 
if  enclosed  and  shut  up  in  a cyst.  Those  that  project  upon  the  peri- 
toneal surface,  are  sustained  there  by  a large  base  or  by  a stout 
pedicle,  consisting  of  peritoneum  and  some  laminee  of  cellular  texture. 

These  polypous  productions,  generally  designated  by  the  term 
fibrous  tumour,  may  be  either  simple  or  multiple.  M.  Roux  has 
seen  as  many  as  ten  or  twelve  protruding  from  the  surface ; we,  on 
one  occasion,  found  eleven  in  the  uterine  parietes  of  an  aged  subject; 
and,  lastly,  M.  Cruveilhier  met  with  three,  with  broad  bases  in  the 
uterine  cavity  of  a subject  thirty  years  old,  who  died  with  phthisis. 

The  shape  of  the  fibrous  tumour  is  almost  always  round ; the 
surface,  like  that  of  the  pediculated  polypus,  is,  in  some  instances, 
smooth;  in  some,  uneven ; in  others,  full  of  anfractuosities,  and,  as 
it  were,  divided  into  several  lobes.  The  size  varies  from  that  of  a 
lentil  or  small  nut  to  that  of  an  adult  head.  In  fine,  the  colour,  con- 
sistence and  origin  being  the  same  as  in  the  pediculated  fibrous  poly- 
pus, we  shall  here  close  our  remarks  upon  those  points,  particularly 
as  we  shall  have  to  recur  to  it  when  we  come  to  consider  the  diag- 
nostics and  treatment  of  fibrous  tumours  in  general. 

The  causes  of  polypi  are  for  the  most  part  difficult  to  ascertain. 
Among  the  predisposing  causes  have  been  mentioned  a lymphatic 
temperament,  the  herpetic,  syphilitic  or  scrofulous  taint ; a chronic 
leucorrhosa,  celibacy,  barrenness,  abortion,  and  sedentary  employ- 
ments, such  as  those  of  the  cook,  the  ironer,  the  seamstress,  &c.  The 
period  of  life,  when  advanced,  appears  also  to  have  some  influence 
upon  the  development  of  polypous  tumours;  indeed,  the  age  from 
thirty  to  forty,  and  that  from  forty  to  fifty  years,  are  the  terms  in 
which  uterine  polypi  are  most  frequently  met  with.  Out  of  fifty-one 
cases  collected  by  authors,  M.  Maigaigne  found  between  26  and  30 
years,  4 cases;  from  30  to  40  years  of  age,  20;  from  40  to  50,  16 
cases  ; from  50  to  60,  4 ; from  60  to  70,  3 ; and  from  70  to  79, 4 cases ; 
in  all,  51  cases.  From  this  statistical  report,  it  appears  that  polypous 
excrescences  are  rare  in  very  aged  persons,  in  young  women,  and 
especially  in  girls  under  twenty-five  years  of  age ; yet  Dessault  ex- 
tirpated a polypus  in  a girl  of  fifteen  years  old,  and  Dr.  Simpson 
foe.  cit.,  p.  22)  informs  us  that  Siebold  has  observed  three  polypi  in 
the  case  of  a girl  with  the  hymen  perfect. 


392 


POLYPUS  OF  THE  WOMB. 


The  fibrous  tumours,  properly  so  called,  that  are  developed  under 
the  same  influences  as  those  that  produce  <he  pediculated  sort,  are 
far  more  frequent  than  the  latter.  Bayle  estimates  at  one-fifth,  the 
number  of  women  beyond  thirty-five  years  of  age,  in  whom  he  met 
with  samples  of  one  or  more  fibrous  tumours.  Portal  found  a still 
larger  proportion,  since,  in  twenty  wombs  that  he  examined  in  1770, 
there  were  thirteen  exhibiting  the  fibrous  excrescence : lastly,  accord- 
ing to  Dupuytren,  there  are  almost  no  specimens  of  the  womb,  in 
aged  women,  that  are  unaffected  with  tumours  of  the  kind  in 
question. 

It  is  equally  difficult  to  say  what  are  the  determining  causes  of 
polypus  uteri.  Nevertheless,  it  may,  as  a general  rule,  be  correct  to 
say  that  the  primary  and  essential  cause  consists  in  a certain  mode 
of  irritation,  whose  persistence,  at  a given  point  of  the  womb  most 
affected,  determines  at  that  point  a new  mode  of  nutrition  and 
vitality , the  precise  nature  of  which  it  will  be  forever  impossible 
to  explain,  but  which  may,  to  a certain  extent,  be  compared  with  the 
ligneous  excrescence  arising  from  punctures  made  by  the  Cynips 
Gat  lx,  or  the  oak  twigs  that  produce  the  nut-gall. 

Many  circumstances  may  dispose  to  the  local  irritation  that  gives 
rise  to  and  favours  the  development  o*f  the  polypus ; such  as  punc- 
tures, fissures,  excoriations,  abusus  coitus,  all  sorts  of  vaginal  dis- 
charges, laborious  labours,  inconsiderate  manipulations  for  the  expe- 
diting of  delivery,  astringent  injections,  and,  indeed,  all  sorts  of  agents 
capable  of  establishing  an  habitual  or  frequently  renewed  irritation 
of  the  genital  organs.  Let  us  add,  that  different  authors  inform  us 
of  the  very  frequent  occurrence  of  polypus  uteri  among  certain  ori- 
ental nations,  whose  women  make  use  of  irritating  pessaries  for  the 
purpose  of  exciting  their  lubricity.  • 

The  primary  symptoms,  or  rational  signs  that  should  lead  to  a 
suspicion  that  a fibrous  polypus  exists  in  the  uterus,  are  about  the 
same  at  first,  whether  the  tumour  is  situated  near  the  peritoneal  sur- 
face, or  whether  it  projects  into  the  cavity  of  the  organ.  The  ordi- 
nary indices  of  the  disorder  consist  of  a set  of  sympathetic  phenomena, 
such  as  vomiting, disgust,  paleness  and  leuco-phlegmasia;  the  menstru- 
ation becomes  more  frequent,  profuse  and  protracted  ; if  the  tumour 
occupies  the  body  of  the  womb,  the  haemorrhages  which,  under  such 
circumstances,  are  still  more  irregular  as  to  their  recurrence,  become, 
in  certain  instances,  so  profuse  as  soon  to  exhaust  the  woman,  who 
at  length  dies  of  debility.  These  serious  symptoms  are  ordinarily 
attended  with  a leucorrhoeal  discharge,  which  is  at  times  fetid  and 
bloody,  and  which  mostly  precedes  the  formation  of  the  polypus;  but 
which,  nevertheless,  does,  in  some  of  the  instances,  fail  to  manifest 
itself  until  after  the  tumonr  has  long  been  formed.  It  is  proper  also 
to  observe  that  where  the  tumour  is  situated  upon  the  cervix,  the 
vagino-uterine  discharge  exists  simply,  that  is  to  say,  without  any 
haemorrhagic  discharges ; in  fine,  we  have  to  add  that  the  patient,  at 
the  same  time,  suffers  from  dragging  sensations  in  the  groins  and  back; 
a sense  of  weight  in  the  hypogastrium,  and  distension  in  the  inte- 
rior of  the  pelvis,  and  at  a more  advanced  stage,  a sort  of  uneasiness 


POLYPUS  OF  THE  WOMB. 


393 


and  compression  about  the  bladder  and  rectum,  that  interferes  with 
the  evacuations  of  stool  and  urine  ; but  these  last  symptoms  do  not 
appear  until  the  magnitude  of  the  tumour  has  become  considerable. 

The  sensible  signs  of  polypus  uteri  are  not  to  be  discovered  in 
every  stage  of  the  malady;  and  further,  they  differ  according  to  the 
situation  and  size  of  the  tumour.  Although  the  menstrual  derange- 
ment, the  nausea,  the  swelling  and  pain  of  the  mammae,  the  change 
in  the  physiognomical  expression,  the  bloated  appearance  of  the  eye- 
lids, and  most  of  the  symptoms  we  have  pointed  out,  may,  in  the 
commencement  of  the  disorder,  sufficiently  show  to  the  medical 
attendant  that  there  is  disease  about  the  uterus,  it  is  often  quite  diffi- 
cult to  say  precisely,  what  is  the  nature  of  the  affection,  while  the 
polypus  continues  to  be  shut  up  within  the  cavity  of  the  organ. 

The  rational  and  sensible  signs , as  well  as  the  progress  of  poly- 
pus uteri,  differ  according  as  the  tumour  happens  to  be  situated  upon 
the  os  tincae,  within  the  cavity  of  the  neck,  or  in  the  cavity  of  the 
womb  proper. 

A polypus  implanted  upon  one  of  the  lips  of  the  cervix,  generally 
presents  no  symptom  beyond  a leucorrhoea,  more  or  less  profuse ; 
and  on  this  account  it  is  often  unsuspected  until  it  becomes  large 
enough  to  descend  near  to  the  vulva,  and  impede  the  expulsion  of 
the  urine.  By  the  examination  per  vaginam,  we  are  enabled  to 
ascertain  the  presence  of  a tumour  of  different  size  and  consistence  in 
different  specimens,  of  ovoidal  shape,  and  adhering  by  its  contracted 
or  pediculated  portion  to  the  cervix.  The  diagnosis  is  completed  by 
bringing  the  tumour  into  view  by  means  of  the  speculum. 

These  polypi  become,  in  some  instances,  so  large  that  they  not 
only  dilate  the  vulva,  but  even  descend  betwixt  the  thighs,  dragging 
the  womb  along  with  them,  but  without  inverting  it.  The  polypi 
that  are  inserted  within  the  canal  of  the  cervix,  are  more  difficult  of 
ascertainment.  By  introducing  a finger  into  the  vagina,  we  feel  a 
tumour  circumscribed  by  a thick  circle,  which  is  the  os  uteri  distended 
by  the  polypus.  Upon  discovering  that  the  tumour  is  implanted 
higher  up  than  the  os  uteri,  we  should  endeavour  to  learn  whether  it 
is  fixed  upon  the  canal  of  the  cervix,  or  upon  the  paries  of  the  ute- 
rine cavity,  properly  so  called.  This  may  be  done,  either  by  carry- 
ing forward  the  point  of  the  finger  to  the  root  of  the  tumour,  if  pos- 
sible, or  by  using  a female  catheter,  with  which  we  may  explore  the 
whole  surface  of  the  cervix ; but  which  will  be  arrested  by  the  neck 
of  the  tumour,  should  it  spring  from  the  wall  of  the  cervix.  As  the 
polypi  that  are  so  situated  are  liable  to  be  more  or  less  violently  com- 
pressed, they  are  more  frequently  than  the  other  kinds  attended  with 
hasmorrhage,  and  as  they  increase  in  size,  they  descend  along  the 
vagina,  and  soon  present  themselves  at  the  vulva. 

Polypous  tumours  adhering  to  the  fundus  uteri  should  be  differently 
regarded,  accordingly  as  they  happen  to  be  still  within  the  cavity  of 
the  womb,  in  the  canal  of  the  cervix  or  in  the  vagina  itself. 

When  they  are  still  within  the  cavity  there  are  no  distinctly  marked 
sensible  signs  of  them ; the  woman  complains  merely  of  a sense  of 
weight  in  the  pelvis,  and  a little  difficulty  in  the  urinary  and  alvine 


394 


POLYPUS  OF  THE  WOMB. 


discharges.  Should  we  discover  by  the  sur-pubal  palpation  and  the 
examination  per  vaginam  that  there  is  a tumour,  we  should  remem- 
ber, that  such  an  enlargement  might  arise  from  a collection  of  blood, 
a calculus,  ora  bunch  of  hydatids;  from  a fibrous  tumour  growing  in 
the  substance  of  the  uterine  paries,  or  even  from  a hypertrophy  of 
the  womb  itself ; in  such  case  the  most  prudent  course  is  to  wait, 
and  in  the  mean  time  prescribe  for  symptoms. 

In  this  early  stage,  the  health  of  the  patient  is  but  little  disturbed, 
yet  they  mostly  complain  of  pain  in  the  groins,  back  and  thighs;  are 
subject  to  leucorrhceal  discharges;  and  their  menses,  which  are  irre- 
gular, and  more  prolonged,  also  return  with  shorter  intervals. 

In  the  second  stage  of  the  development  and  progress  of  the  poly- 
pus, the  tumour,  when  attached  to  the  fundus  uteri,  after  slowly 
dilating  the  cervix,  engages  in  the  canal  like  a wedge,  as  Levret 
remarks,  and  soon  makes  its  appearance  at  the  os  tincse.  The  orifice, 
which  is  now  gaping,  admits  of  the  introduction  of  the  finger,  which 
is  stopped  by  a convex,  resisting,  smooth,  nearly  insensible  tumour, 
the  whole  substance  of  which  may  be  moved  slightly  upwards  by 
gradual  pressure  on  the  part  below.  This  tumour  is  separated  from 
the  circle  of  the  os  uteri,  which  it  fills  up,  by  a circular  sulcus  and  by 
the  projecting  lips  of  the  os  uteri,  all  round  tire  outside  of  which  the 
surgeon  can  feel  nothing  except  the  cul-de-sac  formed  by  the  inver- 
sion of  the  vagina.  When  the  polypus  has  attained  a certain  size 
Within  the  uterine  cavity,  there  is  often  considerable  difficulty  in  its 
escape  through  the  orifice ; and  in  some  instances,  it  may  even  be 
impossible  for  it  to  do  so,  owing  to  the  exceeding  rigidity  of  the  os 
uteri.  The  womb,  in  such  a case,  must  expand,  pari  passu , with  the 
expanding  volume  of  the  tumour;  the  hypogastrium  also  augments 
in  size,  the  breasts  enlarge  from  sympathy,  and  the  pains  experienced 
by  the  patient,  and  which  become  more  and  more  severe,  are  accom- 
panied by  almost  continual  losses  of  blood,  so  that  the  patient  cannot 
move,  while  her  general  feebleness  is  constantly  increasing.  The 
pulse  is  small,  weak  and  frequent ; she  is  attacked  with  repeated 
faintings,  her  face  and  eyes  become  bloated ; dropsy,  which  is  at  first 
partial,  and  then  general,  comes  on,  and  death  is  the  invariable  result 
of  this  scene  of  sufferings,  if  the  physician  does  not  hasten  to  apply 
the  proper  remedies. 

Where  the  polypus  has  fallen  into  the  vagina,  whether  by  slow 
and  gentle  progress,  or  in  a sudden/manner,  after  some  fall  or  shock 
of  any  kind,  or  bearing-down  effort,  like  the  tenesmic  effort  of  labour, 
the  tumour  is  generally  regarded  as  in  its  third  stage.  The  pains  are 
now  suddenly  lessened,  because  the  womb  is  not  now  so  violently 
compressed,  nor  does  it  continue  to  contract  as  before.  But  a copious 
flooding  generally  comes  on,  produced,  as  Levret  and  Sabatier  sup- 
pose, by  the  compression  of  the  superficial  veins  of  the  tumour  by 
the  constricting  cervix  uteri.  This  compression,  which  prevents  the 
return  of  blood  from  the  tumour,  fills  the  veins  to  bursting. 

By  Touching,  when  the  polypus  has  descended  quite  into  the 
vagina,  we  discover  a firm  tumour,  of  a pear  shape,  the  larger  end 
downwards,  while  the  neck  enters  into  the  womb.  The  symptoms 


POLYPUS  OP  THE  WOMB. 


395 


and  sufferings,  which  had  become  less  severe,  soon  acquire  increased 
energy  ; for  the  polypus,  by  increasing  in  size,  comes  to  press  upon 
the  rectum  and  bladder,  more  and  more  severely  every  day,  until 
the  alvine  and  urinary  discharges,  which  had  both  been  only  incom- 
moded before,  now  come  to  be  absolutely  impossible.  The  fundus 
of  the  womb  is  almost  always  drawn  down,  and  we  have  both  a 
case  of  incomplete  inversion  and  prolapsus  uteri  combined.  The 
dragging  pains  in  the  inguinal  and  lumbar  regions  are  felt  with 
greater  force;  the  patient  cannot  stand  upon  her  feet;  and,  now 
the  tumour,  precipitated  by  its  own  weight,  or  by  the  contractions  of 
the  parts,  shows  itself  at  the  labia  pudendi,  and,  being  continually 
soiled  by  the  urine  and  the  utero-vaginal  secretions,  rapidly  passes 
into  a state  of  disease  still  more  to  be  deprecated. 

When,  in  consequence  of  the  large  size  of  the  polypus,  or  the 
rigidity  of  the  uterine  ligaments,  the  tumour  has  been  prevented 
from  descending  low  enough  to  come  out  of  the  vagina,*  the  mucous 
membrane  of  that  canal  becomes  irritated  with  the  contact,  and  even 
inflames,  its  surface  becomes  swollen,  uneven,  tubercular,  and  bathed 
in  putrid  sanies  of  an  extremely  fetid  odour.  To  the  paleness  arising 
from  repeated  floodings,  and  the  general  anaemia  of  the  whole  sys- 
tem, are  now  added  the  straw-yellow  tint  of  the  skin,  which  charac- 
terizes the  cancerous  degeneration  which  almost  invariably  attacks  a 
polypus  thus  retained  and  left  to  the  powers  of  unassisted  nature. 

It  is  a rare  thing  for  a polypus  uteri  to  escape  spontaneously 
through  the  vulva,  either  because  they  remain  stationary,  after  grow- 
ing to  a certain  size  in  the  vagina,  or  because  they  are  extirpated  by 
the  surgeon  before  they  become  large  enough  to  pass  out;  or,  finally, 
because  the  patients  commonly  die  with  the  floodings  or  sero-puru- 
lent  discharges;  but  we  may  see  that,  on  different  occasions,  a large 
polypous  tumour  has  been  seen  depending  betwixt  the  thighs,  and 
pretty  closely  resembling  a complete  prolapsus,  or  more  especially 
an  inversion  of  the  womb. 

The  existence  of  a polypous  tumour  in  the  womb  is  not  necessarily 
an  obstacle  to  conception,  gestation,  or  even  accouchement  at  term. 
Levrett  relates  three  cases,  that  remove  all  doubt  upon  this  point. 
One  of  them  fell  under  his  own  observation,  and  the  other  two  are 
cited  from  Boudon  and  Thoumain.  In  the  two  first  cases,  the  preg- 
nancy was  quite  natural,  and  what  is  most  remarkable  is,  that  during 
its  entire  continuance,  the  polypus  disappeared,  and  did  not  reappear 
until  after  her  delivery.  In  Thoumain’s  case,  the  tumour  caused  the 
woman  to  miscarry,  which  is  the  most  general  result.  Dr.  Huguier 
aggrege  et  prosecteur  of  the  Faculty,  and  one  of  the  most  distin- 
guished young  physicians  of  Paris,  informed  us  that  a girl,  eighteen 
years  of  age,  who,  notwithstanding  she  had  a polypus  attached  to 
the  os  tineas,  which  projected  into  the  vagina,  was  married  and 
became  pregnant.  As  the  tumour  incommoded  her  considerably,  and 

* Baudelocque  saw  a case  of  polypus  uteri  retained  in  the  vagina,  and  of  so  large  a 
size  as  to  fill  the  entire  cavity  of  the  pelvis,  and  push  up  the  womb- as  high  as  the 
umbilicus.  (Recueil.  Period,  de  la  Soc.  Med.,  t.  iv.  p.  137.) 

f Mem.  de  l’Acad.  de  Chir.,  t.  iii. 


396 


POLYPUS  OF  THE  WOMB. 


excited  her  fears  as  to  her  confinement,  she  decided  upon  allowing  it 
to  be  removed,  which  she  had  always  refused  to  do  before.  The 
section  of  the  pedicle,  which  was  done  with  a bistoury,  was  followed 
by  a very  slight  haemorrhage,  but  the  woman  miscarried  the  day 
after  the  operation.  The  physician  who  attended  this  woman,  who 
lives  near  Paris,  told  M.  Huguier  that  she  is  now  (January,  1838,) 
perfectly  well. 

[The  American  Journal  of  the  Medical  Sciences  for  October,  1843,  at  p. 
519,  contains  the  history  of  a case  as  follows  : “The  spontaneous  expulsion 
of  a large  polypus,  two  days  after  the  delivery  of  a fine  healthy  male  child; 
by  John  Davis,  M.  D.,  of  Smithville,  Abbeville  District,  South  Carolina. 

“May  22d,  1843,  I was  summoned  to  Mrs.  C , set.  thirty-two. 

When  I arrived,  I found  her  to  have  been  in  labour  twelve  hours,  with  her 
fifth  child.  The  presentation  was  natural,  and  the  soft  parts  well  dilated; 
the  pains  were,  and  I was  informed  had  been,  pretty  strong  for  three  hours 
previous  to  my  arrival,  yet  they  were  irregular,  intermitting  and  of  little 
effect.  She  was  greatly  exhausted  by  the  continuance  of  her  sufferings  and 
the  violence  of  her  exertions.”  The  relator  proceeds  to  say  that  the  patient 
after  flooding  and  great  debility,  “ was  delivered  of  a large  healthy  male 
child.  The  after-birth  seemed  to  be  slightly  adherent,  but  was  soon  deli- 
vered, with  little  difficulty  and  without  much  haemorrhage.  In  short,  all 
things  seemed  to  do  well,  excepting  the  uncommonly  severe  after-pains,  which 
led  me  to  place  my  hand  over  the  abdomen,  when  I was  a little  surprised  to 
find  it  but  slightly  diminished  in  size,  especially  immediately  over  the  region 
of  the  womb.  This  led  to  a still  further  examination,  per  vaginam,  and,  to 
my  utter  astonishment,  1 discovered  a large  resisisting  tumour  firmly  im- 
pacted in  the  uterus.  Satisfying  myself  as  to  its  character,  I did  not  examine 
as  to  its  location,  as  the  soft  parts  were  very  tender  to  the  touch,  and  as  the 
patient  was  very  much  enfeebled ; nor  was  it  necessary,  as  that  was  not  the 
proper  time  to  search  for  a pedicle  or  neck,  or,  if  its  location  were  ascer- 
tained, to  apply  the  ligature.”  The  Doctor,  having  given  such  directions  as 
seemed  proper,  left  his  patient  doing  well,  but  was  recalled  hastily,  “late  in 
the  afternoon  of  the  day  following;”  but  before  he  arrived,  “she  was  sponta- 
neously delivered  of  a polypus,  weighing  eleven  ounces,  without  the  slightest 
haemorrhage. 

“The  polypus  is  now  in  my  possession  ; its  pedicle  or  stem  is  about  an 
inch  long,  and  about  two  in  circumference ; it  is  similar  to  a fungous'excre- 
scence,  and  is  covered  by  a thick  membrane ; it  is  full  of  large  veins  and 
arteries,  some  of  the  former  being  varicose.” 

The  relator  says,  “this  is  the  19th  of  June,  and  the  lady  has  recovered 
entirely.” 

I presume  there  can  be  no  doubt  as  to  the  authenticity  of  this  case,  and  I look 
upon  it  as  a most  interesting  one,  seeing  that  it  exhibits  an  amazing  example 
of  the  power  of  the  reproductive  organ  to  tolerate  what  might,  a priori,  be 


POLYPUS  OF  THE  WOMB. 


397 


regarded  as  an  intolerable  burthen,  the  weight,  to  wit,  of  the  tumour,  together 
with  the  ovum  and  its  contents.  It  is  highly  probable  that  the  development 
of  the  tumour  must  have  proceeded  at  a great  rate  during  the  latter  months 
of  the  gestation. — M.] 

The  symptoms  of  the  non-pediculated  fibrous  tumour,  or  fibrous 
body  of  the  womb,  are  not  so  marked  as  those  of  the  polypus, 
because  they  produce  less  disorder  in  the  menstrual  atid  other  func- 
tions of  the  organ.  The  sub-peritoneal  fibrous  tumour,  especially 
a small  one,  yields  no  sign  of  its  existence  ; it  only  becomes  evident 
when  it  has  attained  to  a certain  magnitude.  By  resorting  to  th£ 
sur-pubal  palpation,  we  may  perceive  an  indolent  tumour,  of  a cer- 
tain size,  of  a roundish  shape,  and  which  projects  either  in  the  mid- 
dle, or  to  one  side  of  the  belly.  The  patient,  has  an  uneasy  sensation 
in  the  abdomen,  which  is  aggravated  by  any  sudden  movement. 
But  we  ought  to  state  that  these  signs  are  insufficient  to  distinguish, 
ll  priori,  the  sub-peritoneal  fibrous  tumour  from  the  other  kinds  of 
tumours  that  may  happen  to  exist  in  the  pelvis,  such  as  a scirrhus, 
or  an  encysted  dropsy  of  the  ovary.  However,  a mistake  in  the 
diagnosis  can  by  no  means  prove  prejudicial  to  the  patient;  for  in 
these  cases,  all  that  the  medical  attendant  has  to  do,  is  to  remain  a 
mere  spectator  of  the  events  of  the  case,  confining  himself  to  the 
administration  of  a palliative  treatment. 

Fibrous  tumours  in  the  parietes  of  the  corpus  uteri,  especially 
small  ones,  may  also  exist  without  exhibiting  any  signs  of  their  pre- 
sence ; yet  in  most  cases,  we  are  enabled  to  determine  the  question 
as  to  their  existence,  with  considerable  precision.  In  fact,  by  ex- 
ploring the  lower  part  of  the  abdomen,  a tumour  may  be  felt,  which 
grows  daily  in  size  so  as  to  rise  in  some  cases  above  the  umbilicus. 
By  fixing  this  tumour  firmly  with  the  left  hand  pressed  upon  the 
hypogastrium,  and  carrying  the  index  finger  into  the  vagina,  so  as 
to  enable  us  to  push  the  tumour  suddenly  upwards,  the  impulse  is 
communicated  to  the  other  hand ; if,  on  the  contrary,  the  tumour 
being  pushed  by  the  left  hand  from  left  to  right,  we  perceive  a cor- 
responding movement,  but  from  right  to  left,  it  indicates  that  the 
tumour  is  continuous  with  and  part  of  the  womb  itself. 

A non-pediculated  fibrous  body  situated  upon  the  vaginal  surface  of 
the  neck  is  much  more  easily  recognized,  for  it  may  be  detected  by 
means  of  the  speculum,  as  well  as  by  the  Touch.  However,  it  should 
be  observed  that  considerable  obscurity  may  attend  the  diagnosis 
whenever  the  tumour,  instead  of  occupying  the  surface,  is  deep-seated. 
In  such  a case  it  happens  that  the  woman  merely  complains  of  an 
uneasy  sensation,  as  if  produced  by  a foreign  body  in  the  vagina; 
but  this  foreign  body,  which  may  become  of  considerable  size,  really 
consists  of  the  cervix  itself  enlarged  at  some  particular  point,  or  in 
several  places  at  once : let  it  be  also  remarked,  that  women  who  are 
still  regular,  and  who  are  affected  with  fibrous  tumour  of  the  sub- 
stance of  the  womb,  are  generally  subject  to  sanguineous  and  leucor- 
rhoeal  discharges,  more  or  less  profuse  in  different  instances,  and  that 
they  are  commonly  remarkable  for  the  paleness  of  their  complexion, 


398 


POLYPUS  OP  THE  WOMB. 


and  a peculiar  bloat,  accompanied  with  languor ; some  of  them  re- 
cover their  healthy  and  fresh  colour,  and  look  as  they  did  before  the 
attack,  and  indeed  feel  nothing  more  than  the  uneasy  sensations  due 
to  the  presence  of  the  tumour. 

The  differential  diagnosis  of  various  conditions  of  fibrous  polypus 
of  the  womb  have  been  already  pointed  out.  We  shall  now  proceed 
to  speak  of  the  affections  that  may  be  confounded  with  them,  and 
which  have  heretofore  led  to  the  most  serious  mistakes. 

A fibrous  tumour,  contained  within  the  womb,  may  lead  to  the 
supposition  of  pregnancy,  the  more  readily,  as  it  frequently  happens 
that  the  enlargement  of  the  abdomen,  and  the  tumefaction  of  the 
breasts,  are  conjoined  with  numerous  sympathetic  phenomena  that 
attend  the  state  of  gestation.  This  mistake  may  be  avoided  by  recol- 
lecting that  the  enlargement  of  the  -abdomen  proceeds  much  more 
rapidly  in  pregnancy ; that  in  the  case  of  polypus  uteri,  there  is  no 
ballot  tement ; that  the  use  of  the  stethoscope  discloses  neither  the 
pulsations  of  the  foetal  heart  nor  those  of  the  placenta  ; and  lastly, 
that  the  health  of  the  patient  undergoes  changes  that  belong  not  to 
the  gravid  female  in  true  pregnancy. 

An  incomplete  prolapsion  of  the  womb  may  be  readily  distin- 
guished, inasmuch  as  the  tumour  formed  by  the  womb  has  its  apex 
or  smallest  end  downwards,  while  the  contrary  obtains  in  the  poly- 
pus; besides,  at  the  lower  end  of  the  tumour,  we  find  the  os  uteri, 
which  admits  of  the  introduction  into  it  of  the  finger,  or  a bougie,  or 
a stilet. 

A polypus  that  has  descended  betwixt  the  labia  pudendi  has  like- 
wise been  confounded  with  the  complete  descent  of  the  womb.  To 
avoid  such  a mistake,  it  is  only  necessary  to  be  aware,  that  in  this  as 
in  the  preceding  case,  the  tumour  composed  of  the  womb  is  smaller 
below  than  above  ; that  it  is  painful,  reducible,  and  has  a transverse 
slit  which  is  the  orificium  uteri. 

Polypi  have  also  been  confounded  with  complete  and  incomplete 
inversion  of  the  womb.  In  incomplete  inversion  the  neck  is  found 
to  be  partially  dilated,  and  we  may  feel  within  it  a rounded  sphe- 
roidal tumour.  Though  this  be  true  of  the  polypus  beginning  to 
pass  through  the  os  tineas,  the  tumour  exhibits  a different  character 
in  the  two  cases;  for,  when  the  womb  is  incompletely  inverted,  we 
may  reduce,  or  rather  we  may  make  the  tumour  wholly  disappear 
by  pushing  it  upwards.  If  it  be  a polypus,  then,  instead  of  disap- 
pearing under  pressure  of  the  fingers,  the  tumour  continues  to  retain 
the  same  volume  and  preserve  the  same  convexity.  It  is  proper 
also  to  distinguish  betwixt  the  surface  of  the  uterus,  and  that  of  a 
polypus.  The  superficies  of  a polypus,  which  is  insensible,  is  al- 
ways firm,  and  sometimes  smooth,  sometimes  uneven  and  lumpy. 
On  the  other  hand,  the  superficies  of  the  inverted  womb  is  velvety, 
soft,  and  very  sensitive.  Herbiniaux  says,  that  the  inversion  of  the 
womb  is  not  attended  with  floodings  nor  purulent  discharges, 
whereas  they  always  are  present  in  the  case  of  polypus.  We  have 
moreover,  to  add,  that  in  inversion  of  the  womb,  the  finger  will  not 
pass  more  than  a few  lines  upwards  betwixt  the  tumour  and  the 


POLYPUS  OF  THE  WOMB. 


399 


neck ; and  that  the  hypogastric  palpation  shows  the  cavity  of  the 
pelvis  to  be  almost  empty,  but  where  there  is  polypus,  the  womb 
may  be  readily  felt.  Finally,  Malgaigne  has  proposed  an  ingenious 
mode  of  completing  the  diagnosis,  which  consists  in  introducing  a 
male  catheter  into  the  bladder,  so  that  the  point,  when  directed  back- 
wards and  downwards,  until  it  rests  on  the  fundus  of  the  inverted 
organ,  communicates  the  sense  of  touch  to  the  index,  finger  intro- 
duced into  the  vagina,  and  pressed  upon  the  opposite  surface  of  the 
organ. 

A complete  inversion  of  the  womb  may  so  much  the  more  easily 
be  mistaken  for  a polypus,  inasmuch  as  the  tumour  being  swollen 
inferiorly  presents  all  the  appearances,  and  the  shape  of  the  polypus. 
Yet,  an  attentive  examination  will  always  obviate  the  risk  of  mak- 
ing such  a mistake.  It  is  only  requisite  to  know,  that  the  pedicle  of 
the  polypus  is  long,  slender  and  solid,  while  the  contracted  portion 
of  the  inverted  womb  is  short  and  of  a soft  consistence.  Besides,  it 
ought  not  to  be  forgotten,  that  in  inversion,  the  tumour,  which  is  red, 
or  of  a reddish  brown  colour,  is  painful  to  the  touch,  easily  reducible, 
and  always  leaves,  after  its  descent,  a void  above  the  pubis : a poly- 
pus, which,  as  we  have  already  stated,  is  hard,  insensible,  and  of  a 
whitish-yellow  colour,  cannot  return  into  the  vagina  without  exciting 
severe  pain,  nor  without  the  greatest  difficulty.  Where  the  inversion 
has  been  caused  by  the  presence  of  a polypus,  there  will  be  found  two 
tumours,  one  above  and  the  other  below  ; above  the  lower  tumour 
we  may  feel  the  pedicle  of  the  polypus,  which  is  attached  to  the 
fundus  inverted;  in  fine,  a vaginal  hernia,  a cancer  uteri,  may  also 
simulate  a polypus,  but  the  softness,  the  shape,  and  the  reducibility 
of  the  tumour  in  the  former  case,  its  irregularity,  its  being  ulcerated, 
and  the  lancinating  pains  that  attend  it,  in  the  latter,  ought  to  suffice 
to  dispel  all  doubts  on  the  subject. 

The  prognosis  of  fibrous  tumours  of  the  womb,  although  in  general 
serious,  differs  according  to  their  situation,  and  the  symptoms  to 
which  they  give  rise.  Those  that  form  beneath  the  peritoneum,  or 
within  the  parietes  of  the  womb,  though  beyond  the  power  of  the 
physician’s  art,  are  not  necessarily  mortal ; for  women  have  been  seen 
to  reach  an  advanced  age,  with  very  tolerable  health,  though  affected 
in  this  way  for  years. 

The  polypi  that  remain  within  the  uterine  cavity,  are  generally 
more  serious  than  those  that  escape  from  the  orifice,  and  become,  in 
that  way,  accessible  to  the  hand  of  the  surgeon.  Notwithstanding 
it  is  true,  that  the  removal  of  a polypus  has  in  some  instances  caused 
the  death  of  the  patient,  it  has  most  generally  been  followed  by  her 
cure.  We  add  that  the  gravity  of  the  prognosis  is  augmented  by 
the  simultaneous  presence  of  several  distinct  polypous  tumours,  and 
that  those  that  grow  from  the  canal  of  the  cervix  and  from  the  os 
tincae,  are  never  so  dangerous  as  the  other  species.  The  rare  cases 
in  which  a cure  has  followed  the  spontaneous  disruption  of  the  neck 
of  the  tumour,  or  its  passing  into  gangrene,  offered  the  happiest  ter- 
mination of  the  disease.  Lastly, ‘the  size  of  the  pedicle,  the  volume 
of  the  polypus,  the  age  of  the  tumour,  its  degeneration  into  cancer, 


400 


POLYPUS  OF  THE  WOMB. 


and  especially,  the  general  state  or  condition  of  the  patient,  modify 
the  prognosis,  so  as  to  render  it  more  or  less  unfavourable^ 

The  treatment  of  fibrous  polypus  of  the  womb  is  either  palliative 
or  curative ; tumours  situated  within  the  cavity  of  the  organ,  in  its 
proper  texture,  or  on  the  peritoneal  surface,  require  nothing  beyond 
palliative  measures  ; for  example,  hemorrhage  must  be  checked  by 
means  of  rest,  by  a horizontal  posture  and  the  use  of  astringent  in- 
jections. The  patient  should  be  supported  by  an  analeptic  regimen, 
and  by  tonics,  particularly  the  bark,  bitters  and  antiscorbutics.  Un- 
married patients  should  decline  the  marriage  tie ; and  those  who  are 
already  married  should,  by  all  means,  avoid  becoming  pregnant ; for 
the  life  and  that  of  the  child  of  such  a person  would  be  exposed  to 
the  greatest  danger. 

Before  we  proceed  to  speak  of  the  surgical  treatment  of  the  poly- 
pus, it  is  proper  to  mention,  that  where  such  a tumour,  although  still 
retained  within  the  uterine  cavity,  has  begun  to  show  itself  at  the 
orifice  and  given  rise  to  expulsive  and  dilating  pains,  its  escape  might 
be  advantageously  assisted  by  means  of  the  secale  cornutum ; as  has 
been  successfully  attempted  in  a case,  for  which  see  The  Lancet, 
vol.  i.,  Lond.  1828. 

The  surgical  measures  that  have  been  proposed  for  the  removal 
of  polypus  uteri,  when  accessible  to  the  operation,  consist  in  the 
cauterization,  avulsion,  crushing,  torsion,  ligature  or  excision  of  the 
tumour. 

The  application  of  the  actual  cautery,  as  advised  by  Hippocrates,* 
for  the  destruction  of  nasal  polypus,  as  well  as  the  cuth&'ctique  sub- 
stances made  use  of  with  the  same  view  by  Celsus,f  and,  according 
to  the  report  of  Galen,  by  Philoxenus,  Antipater,  Ant.  Musa,±  and 
also  by  Scribonius  Largus,§  Aetius,||  Alexander  Trallianus,1f  and 
other  physicians  of  a remote  antiquity,  was  never  resorted  to  in  the 
treatment  of  the  cases  of  uterine  polypus  mentioned  by  those  prac- 
titioners. As  this  operation  appears  to  us  equally  dangerous  and 
inefficacious,  particularly  for  the  purpose  of  destroying  the  fibrous 
polypus,  we  shall  make  no  further  mention  of  it. 

We  shall  also  say  but  little  as  to  the  practice  of  torsion,  or  that  of 
avulsion  of  the  polypus,  inasmuch  as  we  have  already  treated  of 
them  at  page  387,  and  also  for  the  reason,  that  these  methods, 
•whether  made  use  of  separately  or  together,  are  unsuitable  for  the 
treatment  of  the  fibrous  polypus,  being  adapted  only  for  the  vesicular  or 
cellulo-vascular  kind,  which  are  of  small  size,  of  a soft  consistence, 
and  have  a slender  and  very  friable  pedicle.  Let  us  merely  add, 
that  this  mode,  successfully  used  by  Boudon,**  Mess.  Recamier,  Lis- 

* Hippocrates  de  morb.,  lib.  iii.  p.  471.,  de  effect.,  p.  517. 

f Lib.  vi.  cap.  viii.  t.  ii.  p.  61. 

$ Galen  de  compos,  med.  sac.  loca.,  lib.  iii. 

§ De  composit.  med.  cap.  9.  col.  201.  collect.  Stephan. 

]j  Tetrabib.  ii.  serm.  2.  cap.  92. 

^ Lib.  iii.  cap.  8.  p.  206.  Translation  by  J.  Gaultherius,  of  Andernach.  (24!)  1544. 

**  Levret  (loc.  cit.)  relates  that  Boudon,  after  having  in  vain  attempted  to  put  the 
ligature  on  a polypus  as  large  as  a cricket-ball,  which  was  implanted  in  the  fundus 
uteri,  twisted  it  off  with  his  fingers,  and  thus  effectually  extirpated  it.  Lapeyronie 


POLYPUS  OF  TIIE  WOMB. 


401 


franc,  and  other  practitioners  of  the  present  day,  was  not  recom- 
mended by  Dionis  or  Heister,  except  in  nasal  polypus,  and  not  for  the 
fibrous  polypus  uteri,  an  opinion  that  meets  the  approbation  of 
nearly  all  the  modern  writers. 

The  crushing  process  was  brought  into  use  by  M.  Recamier,  who, 
finding  it  impossible  to  apply  a ligature,  or  to  excise  a polypus  with 
the  treatment  of  which  he  was  charged,  broke  it  to  pieces  with  hook 
forceps,  and  with  his  fingers.  In  another  case  he  divided  the  tumour 
into  two  parts  by  pressing  the  index  finger  against  it,  and  then  re- 
duced it  to  a pulpy  consistence  with  his  hand,  so  that  he  extracted  it 
in  less  than  two  minutes.  In  another  instance,  this  distinguished 
practitioner,  in  consultation  with  Professor  Dupuytren,  made  use  of 
the  combined  methods  of  crushing  and  avulsion,  proceeding  as  in  the 
management  of  a case  of  nasal  polypus.  The  latter  appears  to  me 
preferable  to  the  two  before-mentioned  procedures,  and  should  be 
resorted  to  in  certain  cases,  where  we  can  neither  succeed  in  adjust- 
ing the  ligature,  nor  in  amputating  the  root  of  the  tumour. 

The  ligature  of  polypus  uteri,  and  also  the  operation  by  excision, 
were  recommended  by  JPhilotenus,  (loc.  citat.,)  who,  according  to  the 
historical  researches  we  have  made  on  this  point,  is  the  only  ancient 
author  by  whom  it  has  been  mentioned.  Where  the  works  of  Hip- 
pocrates, and  those  of  the  Arabians,  allude  to  the  subject  of  polypus, 
it  is  always  to  nasal  polypus  that  they  refer ; the  ligature,  employed 
solely  in  this  case,  was  improved  many  centuries  afterwards  by 
Salvid  Fallopias,  but  it  is  to  Levret  that  really  belongs  the  merit  of 
having  employed  it  in  the  cure  of  polypous  tumours  of  the  womb, 
and  of  having  invented  some  very  ingenious  instruments  in  1742, 
for  the  purpose  of  adjusting  the  ligature  upon  the  tumour.  Dr.  Her- 
biniaux,  a physician  at  Brussels,  was  not  satisfied  with  Levret’s 
direction  as  to  the  application  of  the  ligature  to  the  polypus  after  its 
descent  into  the  vagina  only,  but  positively  directs  it  to  be  applied 
even  to  the  tumour,  while  still  contained  within  the  cavity  of  the 
womb.  Several  other  surgeons,  among  whom  we  may  mention  the 
names  of  Theden,  Lecat,  David  of  Rouen,  Brasdor,  Dessault,  Nys- 
ten,  Clarke,  Laugier,  Loefier,  Cullerier,  Bouchetof  Lyons,  Mayor,  of 
Lausanne,  Paul  Dubois,  and  many  others  quoted  by  Meisner  in  his 
Treatise,  have  also  invented  instruments  for  tying  the  polypus  uteri. 
As  those  of  Dessault  are  generally  employed  by  practitioners  at  the 
present  time,  and  as  they  are  moreover  suitable  in  all  the  varieties 
of  the  case,  we  shall  confine  ourselves  to  a description  of  that  dis- 
tinguished surgeon’s  method. 

Dessault’s  instruments  are  three  in  number ; 1,  a port-knot  forceps, 
which  consists  of  a bifurcated  steel  rod,  whose  branches  terminate 
each  in  a half  ring,  which,  when  brought  together,  are  converted 
into  a complete  ring.  This  rod  slides  within  a silver  canula,  so  that 
the  two  branches  of  the  steel  rod  may  be  brought  together,  or  sepa- 

also  menlions  a case  of  polypus  torn  off  in  the  same  manner  By  a midwife.  The 
patient,  who  was  sixty  years  of  age,  recovered  very  well;  although  the  avulsion  was 
performed  with  the  design  of  reducing  a prolapsed  womb,  for  which  the  tumour  was 
mistaken. 

26 


402 


POLYPUS  OF  THE  WOMB. 


rated  by  moving  the  rod  forwards  or  backwards  in  the  canula.  The 
canula,  which  is  two  inches  shorter  than  the  rod,  is  itself  five  or  six 
inches  in  length,  and  has  a notch  at  the  lower  end.  2d,  a port-knot 
canula , about  seven  inches  in  length,  slightly  curved  for  the  purpose 
of  adapting  it  to  the  convexity  of  the  polypus,  and  having  two  rings 
at  one  end,  while  the  other  terminates  in  a blade.  3d,  a knot-tyer , 
which  consists  in  a steel  or  silver  rod  of  a given  length,  with  a ring 
at  one  end,  fixed  at  right  angles  to  the  rod,  while  at  the  other  end, 
which  is  flat,  there  is  a longitudinal  slit  for  receiving  the  ligature. 
For  use,  these  instruments  are  to  be  arranged  as  follows  : in  the  first 
place,  the  canula  of  the  port-knot  forceps  is  to  be  pushed  forward 
until  the  semicircles  unite  into  a complete  ring ; through  this  is  to 
be  passed  one  end  of  a strong  waxed  ligature  two  feet  long;  the  end 
of  the  ligature  is  then  fixed  in  the  notch  at  the  end  of  the  steel  rod ; 
the  other  end  of  the  ligature  is  carried  through  the  port-knot  canula, 
and  secured  to  one  of  the  rings.  Before  proceeding  to  operate,  a 
jointed  speculum  uteri  ought  to  be  provided,  as  well  as  some  small 
fine  sponges,  several  napkins,  some  sweet  oil,  and  several  ligatures ; 
all  things  being  thus  prepared  and  arranged  as  above  mentioned,  we 
proceed  to  the  operation  in  the  following  manner. 

The  patient  having  been  placed  on  the  bed,  in  the  same  manner 
as  for  the  application  of  the  speculum,  and  after  having  again  ascer- 
tained, both  by  touching  and  by  inspection,  the  position  of  the  poly- 
pus, the  thighs  as  well  as  the  labia  are  to  be  separated  by  assistants, 
while  the  port-knot  forceps  and  canula  are  both  introduced  by  the 
surgeon,  who  holds  them  close  to  and  parallel  with  each  other,  pass- 
ing them  upwards  between  the  parietes  of  the  vagina  and  the  tumour, 
and,  if  necessary,  betwixt  the  tumour  and  the  womb.  Having  reached 
the  highest  point  of  the  pedicle,  he  detaches  the  end  of  the  ligature 
which  was  secured  in  the  ring  of  the  canula,  which  he  takes  hold  of 
with  the  right  hand,  while  with  the  left  hand  he  keeps  the  port-knot 
forceps  steady  in  its  place.  He  next  carefully  encircles  by  the  uterine 
extremity  of  the  canula,  the  entire  circumference  of  the  pedicle,  so  as 
to  enclose  it,  by  bringing  the  canula  round  close  to  and  parallel  with 
the  forceps,  which  had  been  kept  unmoved  in  its  place.  Changing 
hands  as  to  the  two  port-knots,  the  canula  is  now  moved  by  the  left 
hand  outside  of  the  forceps,  whence  it  follows,  that  the  two  ends  of 
the  ligature  are  crossed  in  such  a way  that  the  one  in  the  canula 
being  retained  by  the  other,  the  canula  may  be  withdrawn  with- 
out any  fear  of  deranging  the  other  loop  of  the  ligature.  Lastly, 
having  next  untied  the  end  that  was  attached  to  the  forceps,  it  is 
united  with  the  other  so  as  to  pass  them  both  together  through  the 
opening  of  the  knot-tyer,  which  is  pushed  in  as  far  as  the  pedicle, 
while  the  surgeon  tightens  the  two  ends  so  as  to  make  the  loop 
gradually  close  upon  the  polypus ; when  it  is  deemed  that  the  con- 
striction is  sufficiently  great,  the  two  ends  of  the  ligature  are  to  be 
secured  at  the  slit  in  the  knot-tyer,  to  prevent  them  from  relaxing  the 
hold  This  being  done,  the  operation  is  concluded  by  securing  the 
knot-tyer  to  one  of  the  patient’s  thighs  with  a bandage. 

For  the  purpose  of  more  readily  adjusting  the  ligature  to  the 
tumour,  and  particularly  with  a view  to  simplify  the  process  by 


POLYPUS  OF  THE  WOMB. 


403 


making  use  of  a single  instrument,  the  au-  Fig.  40. 

thor  invented  a port-knot  forceps,  which 
he  has  denominated  the  polypodeon,*  and 
which  consists  of  two  blades  eight  inches 
in  length,  and  mounted  like  those  of  the 
common  dissecting  forceps,  but  provided 
with  a very  broad  extremity,  shaped  like 
a spoon,  and  with  a slide  to  approximate 
the  ends  by  moving  a rod  lodged  be- 
twixt them.  This  rod  also  serves  to 
carry  forward  a port-knot  — (port-loop) 
between  the  blades,  and  beyond  the 
uterine  extremity  of  the  instrument,  arm- 
ed with  a simple  loop  of  the  ligature, 
arranged  as  in  the  fig.  40,  annexed.  The 
ends  of  the  ligature  are  passed^  from 
within  outwards  through  the  holes  and 
in  front  of  the  little  pullies  at  the  end  of 
the  stems  of  the  port-loop.  Every  thing 
being  arranged  as  above,  (see  the  figure,) 
the  end  of  the  forceps  is  to  be  carried  up 
along  the  sides  of  the  polypus,  and,  by 
pushing  forward  the  central  rod  by  the 
ring,  the  tumour  will  be  grasped  at  the 
same  time  that  the  port-loop  will  be  car- 
ried up  to  its  pedicle,  that  is  to  say,  to 
the  point  to  which  it  is  designed  to  affix 
it.  Should  the  tumour  be  found  too 
large,  the  carrying  forwards  of  the  loop 
would  be  much  facilitated,  by  pulling 
separately  and  alternately  upon  the  ends 
of  the  ligature,  until  it  reaches,  upon  the 
pedicle,  the  point  on  which  it  is  desirable 
to  affix  it.  When  this  is  done,  which  is 
generally  an  easy  task,  both  ends  of  the 
ligature  are  to  be  pulled  so  as  moderately 
to  compress  the  pedicle : in  the  next 
place,  the  central  rod,  which  moves  the  port-knot,  is  to  be  retracted, 
which  will  withdraw  both  the  port-knot  and  the  branches  of  the  for- 
ceps, so  that  the  whole  instrument  being  now  completely  opened 
again,  is  removed  from  the  vagina,  leaving  the  pedicle  secured  in 
the  loop. 

For  the  purpose  of  completing  the  strangulation  of  the  pedicle,  we 
make  use  of  an  instrument,  consisting  of  a number  of  small  tubes, 
each  about  eight  or  ten  lines  in  length.  To  make  use  of  this  jointed 
constrictor,  {vide  jig.  41,)  we  twist  the  two  ends  of  the  ligature 
into  a single  cord,  and  then,  having  passed  the  cord  through  as 
many  of  the  tubes  as  may  be  necessary,  we  secure  it  to  a small 

* From  the  Greek  ttoXi/ttouc,  polypus  and  tew  from  the  verb  tet»  I tie. 


404 


POLYPUS  OF  THE  WOMB. 


tourniquet,  which  enables  us  to 
tighten  the  noose  at  pleasure.  A 
long  large-eyed  needle,  or  a bodkin 
may  be  used  to  pass  the  cord  more 
expeditiously  through  the  tubes,  or 
a piece  of  wire,  bent  into  a hook  at 
one  end,  may  serve  to  thread  the 
tubes  with. 

This  instrument,  which  we  con- 
structed ten  years  ago,  and  which 
we  supposed  to  have  been  original, 
is  very  analogous  to  one  that  a rich 
citizen  of  Cologne,  M.  Roderick, 
invented  for  the  purpose  of  tying  a 
polypus,  which  some  of  the  Brus- 
sels surgeons,  and  even  the  cele- 
brated Levret  could  not  extract  for 
him.  This  knot-tyer,  en  chapelet , 
which  was  used  by  its  inventor  in 
his  own  case  with  success,  is  pre- 
cisely like  that  which  M.  Mayor,  of 
Lausanne, supposed  himself  to  have 
invented  for  the  same  use,  some  years  ago.  The  constrictor  en 
chapelet  of  M.  Bouchet,  of  Lyons,  and  that  by  M.  Levanier,  of 
Cherbourg,  are  likewise  nearly  similar  to  Roderick’s,  a drawing  of 
which  may  be  seen  in  plate  87,  fig.  9,  of  the  surgical  part  of  the 
Encyclopedic  Methodique,  edited  by  de  Laroche,  and  Petit-Radel 
in  1790. 

Whatsoever  be  the  method  of  applying  the  ligature,  it  ought  to  be  a 
rule  to  draw  it  only  moderately  tight  at  first,  for  the  purpose  of  avoid- 
ing the  bad  consequences  that  might  follow  a too  sudden  and  violent 
strangulation  of  the  pedicle.  It  should  be  afterwards  gradually  tight- 
ened so  as  to  cut  off  the  vascular  communication  between  the  poly- 
pus and  the  womb,  and  thus  cause  the  tumour  to  fall  off.  The  sepa- 
ration takes  place  at  the  very  point  of  contact  of  the  ligature,  and 
not  at  the  insertion  of  the  pedicle  into  the  womb,  as  was  supposed  by 
Levret.*  That  celebrated  practitioner,  and  since  his  day,  Segard,t  Gar- 
dien4  and  M.  Gensoul,  a very  distinguished  surgeon  at  Lyons,  main- 
tained the  notion  that  a polypus,  like  the  umbilical  cord  of  a new- 
born child,  is  detached  at  the  point  of  origin,  whatsoever  may 
have  been  the  point  at  which  the  ligature  is  made.  Although  this 
doctrine,  which  has  been  sustained  by  several  cases,  published 
by  Levret,  Segard,  and  M.  Gensoul,  urges  nothing  contrary  to  the 
laws  of  the  animal  economy,  both  Boyer  and  Dupuytren,  whose 
chirurgical  opinions  are  of  such  great  authority,  look  upon  it  as  dan- 
gerous, and  admissible  only  in  cases  where  the  ligature  has  been 


Fig.  41. 


* Jour.  m6d.,  t.  xxxii.  p.  536. 

f Dissertation  inaugur.,  Nov.  12,  Paris. 

* Trait6  d’accouchement,  &c.,  t.  i.  p.  460. 


POLYPUS  OF  THE  WOMB. 


405 


affixed  very  close  to  the  point  of  insertion.  Though  the  porlion  that 
is  below  the  ligature  falls  off,  that  which  is  above  it  often  continues 
to  live,  to  grow,  and  even  to  reproduce  the  tumour. 

Where  the  pedicle  is  very  slender,  it  sometimes  happens  that  the 
ligature  cuts  through  it,  the  moment  it  is  applied  ; but,  in  general, 
the  tumour  does  not  separate  until  the  fifth  or  sixth  day.  In  a case, 
reported  by  Leblanc,  the  fall  of  the  tumour  was  put  off  for  three 
months.  In  any  case,  where  there  should  happen  to  be  an  attack  of 
violent  pain,  attended  with  sleepiness,  agitation,  tumefaction  of  the 
belly,  and  intense  fever,  haste  should  be  made  to  relax  the  ligature 
and  not  to  tighten  it  again,  nor  even  to  apply  a new  one,  provided  it 
be  wholly  removed,  until  all  the  symptoms  are  completely  relieved, 
either  by  the  relaxation  of  the  ligature  merely,  or  under  the  influ- 
ence of  baths,  injections,  emollient  applications,  or  bleeding,  whether 
general  or  local,  which  ought  to  be  had  recourse  to,  provided  they  be 
indicated  by  any  inflammatory  movements.  The  application  of  a 
ligature  to  polypus  uteri,  has  been  seen  to  produce  metritis  and  peri- 
tonitis* almost  invariably  of  mortal  violence. 

In  case  the  pedicle  be  hard  and  of  a large  size,  the  first  attempts 
at  strangulation  do  not  immediately  interrupt  the  circulation  between 
the  womb  and  the  tumour.  The  latter  swells,  becomes  violet-coloured 
or  blackish;  its  superficial  vessels  becoming  distended  with  blood, 
burst  and  give  rise  to  haemorrhages  that  are  followed  by  horribly  fetid 
discharges,  the  contact  of  which  irritates  the  genital  passages,  and 
may,  by  their  resorption,  give  rise  to  fever  of  a pernicious  character. 
For  the  purpose  of  avoiding,  or  at  least,  of  diminishing  the  troublesome 
consequences  of  the  ligature,  care  should  be  taken  to  make  frequent 
use  of  emollient  injections  into  the  vagina,  and  afterwards,  to  order 
injections  of  bark,  or  what  is  still  better,  injections  composed  with 
chlorur.  of  the  oxid.  of  sodium,  diluted  with  water.  Provided  these 
measures  should  not  succeed  in  lessening  the  bad  symptoms,  and  par- 
ticularly in  case  the  pedicle  of  the  tumour  could  be  easily  got  at,  or 
where,  by  drawing  it  gently  downwards,  it  could  be  brought  within 
reach  of  the  instrument,  we  ought  unhesitatingly  to  remove,  by  an 
incision,  either  with  the  probe-pointed  bistoury,  or  the  scissors,  the 
whole  of  that  portion  of  the  mass  below  the  ligature. 

The  separation  of  the  polypus,  which  is  known  to  be  complete  by 
the  coming  away  of  the  knot-tyer,  with  the  ligature  unbroken,  is  fol- 
lowed by  a purulent  discharge,  which  yields  to  the  use  of  the  bath,  and 
the  common  precautions  as  to  cleanliness.  In  some  instances,  how- 
ever, the  nervous  symptoms,  the  nausea  and  vomiting,  the  pain,  and 
the  inflammatory  symptoms  that  often  accompany  the  adjustment  of 
the  ligature,  continue  to  be  felt  even  after  the  removal  of  the  tumour. 
Notwithstanding  the  disagreeable  circumstances  now  set  forth,  as 
producible  by  the  use  of  the  ligature,  we  agree  with  Drs.  Siebold  and 
Mayer  of  Berlin,  that  it  is  to  be  preferred  to  all  the  other  operations: 
1 , where  we  can  feel  the  pulsation  of  an  artery  in  the  substance  of 
the  tumour : 2d,  where  the  pedicle  is  so  large  as  to  give  reason  to 
fear  that  it  may  comprise  some  large  blood-vessels  ; but,  ill  a case  of 


406 


POLYPUS  OF  THE  WOMB. 


this  sort,  we  think  that  the  tumour  should  be  cut  off  below  the  liga- 
ture, provided  it  should  prove  to  be  too  long  in  separating  the  poly- 
pus, or  give  rise  to  any  of  the  accidents  we  have  spoken  of;  in 
fine,  we  look  upon  the  ligature  as  preferable  to  all  other  means,  in 
cases  where  the  excision  of  the  pedicle  appears  to  be  too  difficult  of 
execution  ; or  where  the  woman  is  so  much  reduced  and  anaemic  as 
to  make  us  fear  the  smallest  loss  of  blood.  It  should  be  mentioned, 
that  the  use  of  the  speculum  is  of  the  greatest  advantage  in  most  of 
the  operations  required  for  the  cure  of  polypus  uteri. 

In  consequence  of  the  serious  objections  to  the  ligature,  and  the 
terrible  accidents  that  sometimes  follow  its  application,  M.  Dupuytren, 
and  most  of  the  modern  practitioners,  prefer  to  remove  the  pedicle 
by  means  of  the  knife.  This  preference  of  excision,  as  a general 
method,  is  fully  justified  by  the  anatomical  character  of  the  fibrous 
polypus;  for,  in  fact,  M.  Hervez  de  Chegoin  (loc.  cit.)  has  proved 
incontestably,  that  the  pedicle  of  the  tumour  is  formed  at  the  expense 
of  a layer  of  the  uterine  tissue,  and  that  the  ligature  is  generally  affixed 
upon  this  very  layer  of  muscular  tissue,  evidently  furnished  by  the 
womb  itself,  and  whose  strangulation  gives  rise  to  the  symptoms  we 
have  described.  Hence  it  may  readily  be  conceived  that  the  section  of 
the  pedicle,  though  it  take  effect  also  upon  this  muscular  layer,  does 
not  give  rise  to  the  bad  symptoms,  because  the  cutting  instrument 
acts  promptly  and  instantly,  instead  of  after  the  slow,  continuous,  and 
irritating  mode  of  the  ligature;  and  it  produces  a simple  wound  from 
which  nothing  is  to  be  feared,  especially  when  we  reflect  upon  the 
number  of  cases  where  the  os  uteri  has  been  amputated,  without  any 
immediate  symptoms  being  occasioned.  • 

The  excision  of  a uterine  polypus  is  as  simple  as  it  is  facile  ; the 
operation,  which  was  adopted  exclusively  by  Dupuytren,  and  had 
been  recommended  by  Philotenus,  and  Moschion,  (de  mul.  affect.) 
and  also  successfully  practised,  according  to  Levret,  by  Tulpius,  Va- 
ter,  and  Frouton,  is  to  be  performed  in  the  following  manner. 

The  patient  being  placed  in  the  same  position  as  the  one  recom- 
mended for  the  operation  with  the  ligature,  the  surgeon  introduces 
the  jointed  speculum,  in  order  first  to  reconnoitre  the  tumour,  and 
then  to  seize  it  more,  effectually  in  a Muzeux  forceps:  he  then  tries  to 
draw  it  downwards  very  gently  and  carefully,  exhorting  the  woman, 
at  the  same  time,  to  bear  down  as  in  labour.  As  soon  as  the  pedicle 
of  the  polypus  becomes  accessible,  it  is  cut  off  with  a pair  of  scissors, 
curved  on  the  flat,  or  with  a long  probe-pointed  bistoury,  that  is 
somewhat  curved  both  on  the  flat  and  edge.  Provided  the  tumour 
should  be  found  to  be  soft,  and  easily  torn,  the  surgeon,  in  imitation 
of  M.  Lisfranc,  might  seize  the  cervix  itself  and  pull  the  uterus  in 
this  way  downwards,  until  the  operation  is  concluded. 

For  the  purpose  of  getting  a firmer  hold,  and  of  more  easily  draw- 
ing down  the  polypus,  without  being  obliged  to  make  use  of  two 
Muzeux  forceps  at  once,  which  is  not  only  inconvenient  but  hazard- 
ous, and  likewise  to  avoid  the  necessity  of  making  use  of  the  for- 
ceps, as  advised  by  Iierbiniaux,  Deneux,  Murat,  Lobstein,  Ilervez 


/ 


POLYPUS  OF  THE  WOMB. 


407 


de  Chegoin,  and  other  authors,  an  inconvenient 
and  difficult  operation,  we  make  use  of  our  quad- 
ruple erigne,  the  uteroceps,  {see  adjoining  figure, 
which  needs  no  explanation ,)  which  seizes  the  tu- 
mour circularly,  and  never  interferes  with,  nor 
masks  any  of  the  manoeuvres,  because  the  hand 
that  holds  it  is  always  placed  opposite  to  the  peri- 
neum. 

Where  the  polypus  resists  steady  traction,  instead 
of  letting  it  go  up  again,  we  hold  it  down  at  the 
same  point  by  giving  the  quadruple  erigne  to  an 
assistant.  Proceeding  along  the  superior  and  con- 
vex surface  of  the  tumour,  we  then,  with  the  right 
hand,  carry  up  our  probe-pointed  bistoury,  which 
is  curved  both  on  the  fiat  and  edge,  so  as  to  reach 
and  divide  the  pedicle  at  its  most  contracted  point ; 
always  guiding  the  instrument  by  the  left  index 
finger. 

Where  the  polypus  is  a small  one,  we  first  bring 
it  into  view  with  the  speculum  uteri,  and  then, 
seizing  it  with  our  forceps,  we  withraw  the  specu- 
lum, and  pulling  the  tumour  down  far  enough,  cut 
it  off.  With  a view  to  prevent  the  patient  from 
suffering  unnecessary  pain,  and  to  perform  the 
operation  with  greater  rapidity,  the  pedicle  might 
be  divided  with  the  sickle-shaped  knife,  which  we 
make  use  of  in  exscinding  at  the  bottom  of  a specu- 
lum the  small  fungous  vegetations  that  are  occasionally 
to  be  found  growing  upon  the  os  tincae.  ( Vide  the  fig. 
38.) 


42. 


Fig.  43. 


In  a case  where  the  tumour  should  prove  to  be  too 
large  to  pass  readily  through  the  external  organs,  which 
is,  however,  a rare  occurrence,  it  might  become  necessary 
to  enlarge  the  orifice  by  cutting  through  the  perineal 
membrane,  the  fourchette.  Or  the  tumour,  as  in  Be- 
dard’s case,*  might  be  divided  into  two  equal  longitudi- 
nal portions,  and  removed  from  the  vagina  in  succession. 

Lastly,  where  the  root  of  the  tumour  is  still  concealed 
within  the  uterine  cavity,  the  surgeon  might  try  the  semi- 
inversion, recommended  by  Baudelocque,  for  it  is  well 
known,  that  to  such  a partial  inversion  of  the  womb, 
lasting  but  for  a few  moments,  there  is  attached  no 
other  inconvenience  than  that  of  being,  in  the  case  of 
a virgin,  or  a woman  who  has  never  had  children,  very 
difficult,  or  even  impracticable.  Under  such  circum- 
stances recourse  might  be  had  to  the  ligature,  or  to  the 
division  of  the  circle  of  the  os  uteri  itself,  by  means  of  the  bis- 


* Acad,  de  Medecine,  Jan.  27,  1825.  M.  Chasagnac,  in  a similar  case,  success- 
fully removed  a large  fragment  of  a wedge-shape,  from  a fibrous  polypus. 


/ 


408 


POLYPUS  OF  THE  WOMB. 


toury,  according  to  the  plan  practised  by  Dupuytren  and  Hervez  de 
Chegoin.  The  former  of  these  surgeons,  in  two  cases  of  the  sort, 
made  one  incision  into  the  posterior  part  of  the  cervix,  and  one  on 
each  side,  after  which  the  polypous  tumours  were  extracted  easily, 
and  with  complete  success  in  both  cases.* 

Should  the  polypus  have  contracted  adhesions  to  the  vagina,  they 
ought  to  be  loosened  gradually,  by  means  of  scissors  bent  on  the  flat, 
before  drawing  down  and  cutting  off  the  pedicle.  Lastly,  should  the 
case  be  one  in  which  the  polypus  is  separated  from  the  surface  from 
which  it  springs  by  a deep  or  a shallow  fissure,  or  by  a very  short 
and  thick  pedicle,  the  operation  need  not,  on  that  account,  be  re- 
nounced, but  even  where  the  pedicle  can  not  be  got  at,  as  muph  of 
the  tumour  as  can  be  got  away,  ought  to  be  removed,  as  was  suc- 
cessfully done  by  M.  Lisfranc ; for  a number  of  instances  exist,  that 
go  to  show  that  the  part  left  after  the  operation  becomes  detached,  or 
undergoes  a process  of  suppuration.  In  imitation  of  the  example 
set  by  M.  Recamier,  we  might  likewise  divide,  by  a longitudinal  in- 
cision, the  layer  of  muscular  tissue  that  envelops  the  morbid  fibrous 
material,  and  then  detach  or  eradicate  the  latter  with  the  fingers  or 
with  a scalpel  handle,  just  as  a kernel  is  taken  out  of  the  fruit  that 
encloses  it.  The  ragged  membranous  laminae  that  are  left  by  this 
process  of  enucleation,  retract  and  heal  over  as  they  return  to  their 
natural  situations,  or  they  are  partially  lost  in  the  suppurative  opera- 
tions that  ensue.  It  is  right  to  remark,  that  when  a polypus  has 
formed  adhesions  to  the  muscular  membrane  that  covers  it,  there  is 
almost  always  a vascular  connection  established,  and  hence,  if  the 
whole  tumour  is  not  taken  away,  the  remainder  continues  to  live,  and 
at  length  requires  the  performance  of  another  operation,  instances  of 
the  kind  having  been  reported  by  various  authors,  as  Herbiniaux 
and  MM.  Recamier  and  Lisfranc. 

The  dread  of  haemorrhage,  which  had  caused  the  operation  by  the 
knife  to  be  rejected  in  the  case  of  polypus  uteri,  in  universal  prefer- 
ence of  the  ligature,  is  not  justified,  except,  perhaps,  by  the  case 
related  by  Zacutus  Lusitanus,t  who  died  at  Amsterdam  in  1642. 
This  celebrated  Portuguese  who,  from  fear  of  the  Inquisition, migrated 
to  Holland,  informs  us  that  a quack,  having  removed  by  incision,  a 
polypus  of  the  size  of  an  almond,  lost  his  patient  with  the  haemor- 
rhage that  followed  his  operation.  However  this  may  have  been,  it 
ought  to  be  stated  that  such  a serious  consequence  was  never  known 
to  follow  the  numerous  operations  performed  with  the  knife  by  Du- 
puytren.  In  only  a single  case,  was  some  special  attention  required 

* Revue  Medicale,  tom.  ii.  p.  382,  1829,  and  the  Nouvelles  Elements  de  path.  med. 
chirurg.  of  Mess.  Roche  and  Sanson. 

| M.  Berat'd  ( Dissertations  sur  plusieurs  points  d’anaf.  pathol.  14  Feb.  1825),  cites 
the  case  of  a polypus  having  a primitive  insertion  at  the  fundus  uteri,  but  which,  in 
consequence  of  adhesion  to  the  vagina,  was  attached  to  the  posterior  wall  of  the 
vagina,  as  by  a second  pedicle.  Professor  Alibert  informed  qs  that  he  had  seen  a 
patient  with  a double  tumour  formed  in  the  recto-vaginal  septum,  part  of  which  came 
out  at  the  anus  and  the  other  part  at  the  vulva;  the  two  portions,  having  inflamed, 
cohered,  so  as  to  inclose  the  perineum  in  a sort  of  ring. 


POLYPUS  OF  THE  WOMB. 


409 


on  account  of  the  loss  of  blood.  The  case  reported  by  Herbiniaux, 
Boyer’s,  all  those  convincing  ones  by  MM.  Siebold,  Mayer,  Lisfranc, 
Idervez  de  Chegoin,  Villeneuve,  Velpeau,  Lejeune  and  a number  of 
operations  of  the  same  sort,  exempt  from  consecutive  haemorrhage, 
prove  how  greatly  exaggerated  have  been  the  fears  entertained  upon 
this  point.  Besides,  if  the  patient  should  be  attacked  with  haemor- 
rhage of  an  alarming  character,  it  could  be  treated  by  means  of 
astringent  injections,  cold  applications  to  the  thighs  and  hypogaster, 
and  in  fine,  with  the  tampon,  composed  of  pledgets  of  lint,  moistened 
with  an  astringent  preparation,  or  sprinkled  with  resin,  or  where  that 
could  not  be  readily  procured,  with  common  ashes. 

In  a comparison  of  the  ligature  with  the  excision,  the  advantage 
always  is  on  the  side  of  the  latter.  In  fact,  if  on  the  one  hand  we 
reflect  that  the  ablation  by  the  knife  is  less  painful,  that  the  woman 
is  promptly  relieved,  and  that  the  fears  on  the  subject  of  haemorrhage 
are  nearly  chimerical  ;*  and,  on  the  other  hand,  that  the  ligature 
produces  severe  pain,  and  the  fall  of  the  tumour  requires  a considera- 
ble lapse  of  time  ; that  the  ligature  must  be  tightened  every  day,  that 
the  patient  must  be  visited  and  examined  day  after  day,  and,  finally, 
that  fatal  inflammation  may  follow  the  strangulation  of  the  pedicle, 
and  especially  that  the  patient  may  be  affected  with  nervous  and 
adynamic  symptoms,  arising  from  the  putrefaction  of  the  polypus 
and  absorption  of  the  fetid  discharges ; when  we  take  into  considera- 
tion the  inconveniences  and  advantages  on  both  sides  of  these  surgi- 
cal measures,  we  ought  not.  to  hesitate  in  looking  upon  the  operation 
by  excision  as  the  general  rule,  and  that  by  the  ligature  as  the  excep- 
tional case.  To  conclude,  let  us  add,  that  both  operations  are  to  be 
regarded  as  inadmissible,  where  the  tumour  is  wholly  enclosed  within 
the  cavity  of  the  womb  ; where  we  are  assured  that  it  is  not  single, 
and  where  we  have  ascertained  that  there  are  other  tumours  in  the 
organ,  yet  not  within  reach  of  the  chirurgical  means  of  assistance. 

The  cares  required  by  patients,  subsequently  to  the  operation,  con- 
sist in  the  exhibition  of  injections,  at  first  of  an  emollient,  and  then 
of  a detergent  and  slightly  tonic  quality ; should  any  inflammatory 
symptoms  show  themselves,  and  particularly,  should  the  patient  be  of 
a plethoric  habit,  we  ought  to  have  recourse  to  venesection,  cautiously 
administered,  and  to  all  the  antiphlogistic  measures,  both  general  and 
local.  Let  it  also  be  said  that  Dupuytren,  for  the  purpose  of  obvi- 
ating the  irritation  and  pain  that  are  often  found  to  follow  the  re- 
moval of  the  polypus,  established  it  as  a general  rule,  that  the  patient 
should  be  bled  from  time  to  time,  in  small  quantity  at  each  bleeding, 
provided  she  had  been  long  subject  to  floodings,  which  are  entirely 
stopped  by  the  operation. 

It  remains  for  us  to  speak  of  polypus  of  the  vulva  and  vagina  ; the 
former  are  easily  recognized,  and  the  treatment  of  them  so  simple  that 

* The  ligature  may,  in  certain  cases,  be  followed  by  haemorrhage;  for  M.  Monfal- 
con (Diet,  cfes  Sci.  Med.)  says  that  “ M.  Dubois  was  so  unfortunate  as,  on  several 
different  occasions,  to  lose,  by  rapid  haemorrhage,  the  patients  relieved  of  polypus 
uteri  by  the  application  of  the  ligature.” 


410 


INFLAMMATION  OF  THE  OVARIA  AND  TUBES. 


it  is  only  necessary  to  state  that  they  may  be  met  with  in  practice. 
The  latter,  which  are  quite  analogous  to  those  of  the  womb,  but  not 
so  generally  of  the  fibrous  sort,  are  readily  distinguished  by  the.  touch, 
which  shows  that  the  os  tincse,  and  the  entire  surface  of  the  cervix, 
are  completely  free,  and  have  no  connection  with  the  polypous  tumour. 
Any  mistake  ought  to  be  regarded  as  out  of  the  question,  where  we 
can  touch  the  pedicle  and  ascertain  the  precise  point  of  its  insertion  on 
some  part  of  the  vaginal  walls.  All  we  have  to  say  is  that  the  vaginal 
polypus  produces  less  frequent  haemorrhage  than  polypus  uteri,  and 
that  the  surgical  treatment  most  generally  suitable  for  the  case,  is  the 
ligature,  which  may  be  most  easily  applied  merely  by  means  of  our 
jointed  constrictor. — ( Vide  fig.  41,  p.  404.)  Where  the  tumour  is  deep 
seated,  it  should  be  brought  into  view  with  the  speculum  uteri, 
taking  care  to  lodge  it  in  the  space  betwixt  the  blades  of  the  instru- 
ment. 

INFLAMMATION  OF  THE  OVARIA  AND  FALLpPIAN  TUBES. 

Of  all  the  disorders  of  the  ovaries  and  tubes,  the  most  common, 
beyond  doubt,  is  inflammation,  known  under  the  title  of  ovaritis  or 
oophoritis.  Although  these  organs,  do  participate,  more  or  less,  in 
the  phlegmasias  of  the  uterine  tissue,  it  happens  that  they  may  be 
separately  attacked  with  inflammation  of  an  acute  character,  or  in  a 
subacute  or  chronic  form.  But  as  the  ligaments  of  the  womb,  the 
tubes  and  the  ovaries,  are  closely  united,  and  are,  moreover,  deeply 
seated  in  the  abdomen,  the  signs  of  inflammation  are  common  to  the 
whole  of  them ; for  it  is  almost  impossible  to  distinguish  which  of  the 
parts  is  the  special  seat  of  the  disorder.  We  add,  moreover,  that  the 
existence  of  the  lesion  generally  eludes  observation  until  the  morbid 
development  of  the  uterine  appendages  becomes  sufficiently  consi- 
derable to  be  felt  through  the  parietes  of  the  abdomen. 

An  acute  inflammation  of  the  ovaries,  chiefly  met  with  in  young 
females,  is  generally  produced  by  laborious  parturition,  by  a suppres- 
sion of  the  lochia,  an  acute  puerperal  metritis,  and  especially  by  an 
inflammation  of  the  uterine  peritoneal  membrane. 

The  causes  which  have  been  considered  capable  of  producing  this 
disorder,  independently  of  the  circumstances  of  the  puerperal  condi- 
tion, are,  a blow,  a fall,  a wound  and  contusion  in  the  iliac  region,  a 
degree  of  nervous  sur-excitement,  and  all  the  irritations  connected 
with  erotic  excitements ; and,  in  fine,  whatever  causes  may  serve  to 
give  rise  to  an  attack  of  metritis,  such  as  sudden  refrigeration  of  the 
body,  the  suppression  of  the  menses,  or  a painful  menstruation  which 
is  difficult  and  imperfect ; the  abuse  of  emmenagogues ; the  use  of 
substances  designed  to  produce  abortion,  and  such  exciting  articles 
as  are  known  under  the  denomination  of  aphrodisiacs. 

The  symptoms  of  inflammation  of  the  ovaria  are  : a sense  of  heat 
and  a pungent  pain  in  either  side  of  the  pelvic  excavation.  Both  the 
touch  and  inspection  disclose  a rounded  swelling,  resisting,  and  very 
sensitive  to  pressure,  situated  in  the  part.  The  swelling  and  tension 


INFLAMMATION  OF  THE  OVARIA  AND  TUBES.  411 

are  propagated  over  the  whole  abdomen,  and  the  pain  almost 
always  shoots  towards  the  loins,  and  also  extends  down  the  thighs, 
which  are  the  seats  of  an  extreme  degree  of  torpor  and  lassitude. 
The  belly,  which,  in  some  cases,  is  pretty  supple  to  the  touch,  and 
may  remain  so  throughout  the  whole  progress  of  the  malady,  be- 
comes more  and  more  sensitive  as  the  disease  extends;  and  it  fre- 
quently  happens  that  the  lightest  touch  of  the  hand  gives  rise  to 
spasmodic  contraction  of  the  features  and  convulsive  motions  of  the 
lower  limbs.  When  both  of  the  ovaries  are  affected  at  the  same 
time,  which  is  mostly  the  case,  two  tumours  are  produced,  at  first 
distinct  from  each  other,  but  which  gradually  approach  each  other, 
and  at  length  unite  into  one  swelling,  under  the  median  line.  To 
these  local  symptoms  are  conjoined  frequent  pulse,  heat  and  dry- 
ness of  the  skin,  ardent  thirst,  extreme  disgust,  violent  agitation, 
difficult  and  painful  expulsion,  both  of  urine  and  stool ; and,  lastly, 
nausea  and  vomiting,  showing  that  the  stomach  sympathizes  in  the 
ovarian  phlegmasia.  We  should  observe  that  all  the  general  symp- 
toms resulting  from  this  disorder,  vary  not  only  according  to  the 
individual  disposition,  but  also  in  proportion  to  the  intenseness  of 
the  attack  and  its  complication  with  acute  metritis  and  peritonitis, 
which  so  often  coexist  with  acute  ovaritis,  and  particularly  with 
puerperal  ovaritis. 

The  progress  of  the  disorder,  when  acute,  is  about  the  same  as 
that  of  an  acute  inflammation  of  the  uterine  tissue  itself.  It  may 
terminate  in  resolution,  from  the  eighth  to  the  eleventh  day.  In 
such  case,  the  menses  return,  and  the  lochia  increase  in  quantity;  the 
pain,  as  well  as  both  the  general  and  local  symptoms,  gradually 
diminish;  the  tumour,  whether  single  or  double,  retires,  little  by 
little,  and  at  length  disappears  entirely.  A case  of  acute  ovaritis 
may  also  prove  rapidly  fatal,  particularly  where  it  is  complicated 
with  an  attack  of  puerperal  metro-peritonitis,  which  is  itself  so  fre- 
quently mortal.  This  affection  may  also  end  in  suppuration,  from 
the  twelfth  to  the  fourteenth  day.  Such  a termination  is  indicated 
by  alternate  chills  and  flushings,  by  softness  of  the  pulse,  an  increase 
of  throbbing  pain,  coincidentiy  with  the  lessening  of  the  general 
symptoms.  Where  this  happens,  the  pus  escapes  by  different  routes; 
it  has  been  seen  to  penetrate  into  the  peritoneal  sac,  and  give  rise 
to  an  attack  of  peritonitis,  which  is  almost  always  the  cause  of  a 
speedy  dissolution.  We  witnessed  a case  of  this  kind  at  Dupuytren’s 
clinic:  Dr.  Seymour*  also  reports  a sample  of  the  kind;  and  M. 
Andral  cites  from  Brehm  (Die.  de  Med. , in  24  vols.,t.  16)  the  case  of  a 
girl  who,  after  suffering  for  fourteen  days  with  a severe  pain  in  the 
right  side  of  the  pelvis,  was  seized,  after  some  time,  with  all  the 
symptoms  of  a peritonitis,  that  soon  proved  fatal.  In  addition  to  the 
traces  of  peritoneal  inflammation,  it  was  ascertained  by  the  autopsy 
that  the  pus  which  had  filled  the  right  ovary  had  escaped  through 
two  large  openings  into  the  peritoneal  sac.  In  some  instances,  it 
may  happen  that  the  acute  inflammation,  produced  by  the  purulent 


* Illustr.  of  the  Principal  Dis.  of  the  Ovaria,  p.  40. 


412 


INFLAMMATION  OF  THE  OVARIA  AND  TUBES. 


collection,  shall  act  in  a salutary  manner,  and  cause  the  formation  of 
adhesions,  which,  by  preventing  the  pus  from  spreading  itself  abroad, 
allows  of  its  directing  itself  to  the  external  surface,  or  to  become  one 
of  the  means  of  creating  an  encysted  tumour. 

In  most  cases,  the  pus  is  directed  towards  the  colon  or  the  rectum, 
and,  discharging  itself  into  the  intestine,  at  last  passes  out  at  the  anus. 
Facts  of  this  kind  are  stated  by  Madame  Boivin;*  by  Messrs.  Nau- 
che,t  Dnges,f  Martin  Solon, § and  other  practitioners. 

The  pus  may  also  find  issue  from  the  vulva,  either  by  making  an 
opening  into  the  vagina  or  by  passing  along  the  cavity  of  the  Fallo- 
pian tube. ||  The  pus  has  also  been  observed  to  move  towards  the 
iliac  region,  and  open  at  that  point. 

[I  saw  a case,  a few  years  since,  in  a young  woman,  the  mother  of  two 
children,  who,  after  her  confinement  with  the  third,  was  seized  with  the 
symptoms  of  ovaritis.  The  malady  was  most  painful,  and  extended  consi- 
derably into  the  peritoneum  near  the  left  ovary.  A hard  and  extremely 
painful  tumour  gradually  formed  in  the  lower  part  of  the  left  iliac  region, 
which  fluctuated  and  pointed.  I opened  it  with  a common  lancet,  and  dis- 
charged near  a pint  of  pus.  The  purulent  discharge  continued  for  many 
days,  but  the  patient  at  length  recovered  her  health  very  completely.  I saw 
a similar  collection  that  attacked  a lady  affected  with  carcinoma  of  the  cervix 
uteri.  The  discharge  was  very  great,  but  the  abscess  was  cured.  She 
ultimately  died  with  ulcerated  carcinoma  uteri. — M.] 

Some  cases  are  met  with,  in  which  the  purulent  product  passes 
into  the  urinary  bladder,  and  then  escapes  through  the  urethra,  as  in 
specimens  described  by  Messrs.  Murat,  Andral  and  Duges.  In  fine, 
acute  ovaritis  may  terminate  in  gangrene  ; but  it  most  generally 
passes  into  a chronic  form  of  inflammation,  which  is  known  by  a 
marked  diminution  of  all  the  symptoms.  In  this  case,  the  engorge- 
ment of  the  ovary  may  be  dissipated  in  the  course  of  time,  longer  or 
shorter,  or,  what  much  more  commonly  occurs,  the  chronic  inflam- 
mation may  be  indefinitely  prolonged,  the  ovary  becoming  indurated, 
scirrhous  or  cancerous,  or  undergoing  various  alterations,  which  we 
shall  treat  of  presently,  and  whose  symptoms  differ  according  to  their 
several  kinds.  But  it  is  quite  true,  that  although  the  different  vital 
lesions  to  which  the  ovaries  are  exposed,  are  almost  always  produced 
by  an  attack  of  inflammation,  either  acute  or  chronic,  they  may  yet, 
in  some  instances,  arise  and  make  progressive  developments,  inde- 
pendently of  any  appreciable  signs  of  inflammation. 

* Recherches  sur  une  des  causes  de  l’avortemen,  1828. 

f Des  maladies  propres  aux  femmes,  p.  375. 

* Maladies  de  l’uterus,  t.  ii.  p.  572. 

§ Diet,  de  med.  et  chirurg.,  prat.  t.  xii.  p.  416. 

||  Iu  the  fifth  case  of  the  Mem.  de  l’Acad.  des  Sciences,  for  the  year  1700,  is  an 
account  of  a woman  who  had  never  menstruated,  and  in  whom,  after  death,  was 
found  an  abscess  of  the  ovary  which  emptied  itself  into  the  vagina  along  the  cavity 
of  the  Fallopian  tube,  and  through  the  womb.  M.  Laumonier  (Mem.  de  laSoc.  Roy- 
ale  de  M6decine,  1782,  p.  300,)  reports  a very  similar  case. 


INFLAMMATION  OF  THE  OVARIA  AND  TUBES. 


413 


The  diagnosis  of  ovaritis  is,  for  the  most  part,  an  obscure  one. 
While  we  may  clearly  distinguish  it  (rorn  an  attack  of  metritis,  or 
cystitis,  by  reference  to  the  situation  of  the  'affected  part,  we  may 
very  easily  confound  it  with  inflammation  of  the  parts  about  the  side 
of  the  womb,  and  particularly  with  inflammation  of  the  cellular  tex- 
ture, which  is  so  abundant  in  that  vicinity.  An  ovaritis  may  also 
very  easily  be  confounded  with  inflammation  of  the  Fallopian  tube, 
and  can  be  distinguished  from  it,  during  life,  only  by  the  absence  of 
the  rounded  swelling  in  one  side  of  the  pelvis.  Fortunately,  a mis- 
take in  the  diagnosis  of  these  different  cases  cannot  lead  to  any  unfa- 
vourable consequences ; for  the  treatment  indicated  for  the  one  is 
equally  applicable  to  the  other  of  these  affections.  Besides,  it  is  an 
uncommon  circumstance  for  the  ovaries  and  the  ligaments  of  the 
womb  to  become  inflamed  without  drawing  the  relaxed  parts  into  a 
participation  in  the  malady ; or  they  are  even,  most  generally,  the 
radiating  points  of  the  inflammation. 

The  prognosis  of  acute  ovaritis  depends  upon  the  extent  and 
intensity  of  the  disease ; it  is  much  more  serious  when  co-existent 
with  puerperal  metritis  and  peritonitis,  and  when  developed  like 
the  last  named  affections,  under  an  epidemic  influence.  Chronic 
ovaritis  is  rarely  cured ; it  almost  always  passes  into  a state  of  scirr- 
hous induration,  which,  however,  in  many  specimens,  does  not  hin- 
der the  patient  from  drawing  out  a long-continued  existence. 

[I  interrupt  for  a moment  the  detail,  for  the  purpose  of  protesting  against 
the  plan  of  our  author,  of  treating  as  a case  of  ovaritis,  those  terrible  in- 
flammations that  ensue  upon  the  puerperal  state,  and  commonly  known  as 
child-bed  or  puerperal  fever.  I apprehend,  that  in  the  management  of  a case 
of  the  disorder  in  question,  particularly  under  an  epidemic  influence,  the 
practitioner  will  find  it  necessary  to  combat  not  an  ovaritis,  (although  the 
ovary  is  a most  common  seat  of  the  inflammation,)  but  a general  inflamma- 
tion of  the  tissues  invested  by  the  peritoneum.  The  womb,  the  tubes,  the 
ovaries,  the  intestines,  the  spleen,  liver  and  stomach,  are  all  involved  in  one 
common  inflammation  of  their  serous  surfaces;  and  though  it  is  quite  true 
that  we  find  deposits  of  pus  beneath  the  ovaric  peritoneum,  we  also  find 
similar  depositions  below  the  uterine  peritoneum,  and  within  the  ligamenta 
lata,  in  the  veins,  and  even  in  the  absorbents  of  the  uterus  itself.  It  is  dispa- 
raging the  idea  of  a puerperal  fever  to  call  it  an  ovaritis. — M.] 

Anatomical  character.  In  its  acute  stage  the  ovaries  are  found 
swollen,  red,  and  more  or  less  injected  with  blood ; their  vesicles  are 
always  larger  than  in  the  natural  state ; sometimes  they  are  found 
larger  than  an  orange,  and  their  tissue,  which  is  soft  and  friable,  is 
infiltrated  with  a yellowish  or  violet-coloured  serous  fluid,  or  in  it 
contains  collections  of  pus,  either  liquid  or  in  a concrete  form;  the 
pus  may  also  be  seen  collected  in  one,  or  in  several  cysts  of  various 
sizes,  and  then  the  ovary  will  generally  be  found  to  have  formed  ad- 
hesions to  the  adjacent  parts.  Finally,  when  the  disorder  is  of  an 


414 


INFLAMMATION  OF  THE  OVARIA  AND  TUBES. 


ancient  date,  the  organ  is  but  littled  injected  with  blood,  and  is,  in  a 
measure,  destitute  of  capillary  vessels. 

The  treatment  of  acute  ovaritis  consists  in  the  employment  of 
venesection,  which  should  be  reiterated  according  to  the  violence  of 
the  symptoms  and  the  strength  of  the  patient ; recourse  should  be 
had,  from  time  to  time,  to  the  application  of  leeches  to  the  groin, 
near  the  affected  part,  Cataplasms  should  also  be  laid  upon  the  hypo- 
gastrium ; baths,  emollient  and  slightly  narcotic  injections,  demul- 
cent and  diluting  drinks,  slightly  acidulated,  should  be  prescribed ; 
lastly,  rigorous  diet  and  absolute  rest  add  greatly  to  the  efficacy  of 
the  other  antiphlogistic  measures. 

Should  the  disease  terminate  in  suppuration,  so  as  to  allow  us  to 
perceive  an  evident  fluctuation  at  the  groin,  or  within  the  vagina, 
there  ought  to  be  no  haste  to  open  the  abscess  and  draw  oft'  the  pus ; 
but  we  ought  to  wait,  in  order  to  allow  of  the  formation  of  adhesions. 
Upon  coming  to  the  determination  to  open  the  abscess,  it  would  be 
well,  if  the  groin  be  the  spot  selected,  to  apply  a portion  of  caustic 
paste  to  the  point  chosen  for  the  incision;  such  a proceeding  possesses 
the  twofold  advantage  of  promoting  adhesion,  and  the  formation 
of  an  eschar  through  the  centre  of  which  the  opening  can  be  made 
with  the  bistoury.  In  case  the  fluctuation  should  be  felt  in  the  va- 
gina, instead  of  at  the  inguinal  region,  the  abscess  should  be  opened 
with  a bistoury  or  a trocar;  the  absorption  of  such  portions  of  the  pus 
as  could  not  be  discharged,  might  be  afterwards  promoted  by  the  use 
of  diaphoretic  drinks,  and  some  gentle  purgative  doses.  When  the 
disease  ends  in  gangrene,  recourse  might  be  had  to  blisters,  frictions, 
and  camphorated  lotions  externally,  with  the  use  of  antiseptics  and 
chlorurets  internally  used. 

In  those  instances  where  the  ovaritis  has  already  passed  into  the 
chronic  state,  or  had  assumed,  from  the  beginning,  a chronic  cha- 
racter, resort  should  be  had  to  external  revulsive  measures,  such  as 
blisters,  issues,  moxas,  setons  established  in  the  iliac  region,  and  fric- 
tions at  the  same  point,  with  antimoniated  ointment,  mercurial  oint- 
ment, or  ointment  of  hydriodate  of  potash ; douches  of  the  sulphur 
waters  of  Aix  in  Savoy,  or  of  Bareges,  to  be  directed  on  to  the 
groins,  or  in  the  ascending  form  to  the  vagina ; lastly,  leeches  in 
small  numbers  ; topical  applications  of  extract  of  cicuta,  of  colchicum 
or  opium,  and  narcotic  injections.  Such,  perhaps,  is  the  entire  series 
of  external  measures  demanded  for  the  treatment  of  chronic  ovaritis, 
whether  primitive  or  consecutive  in  its  attack.  At  the  same  time 
that  we  are  administering  remedies  of  the  kind  above  pointed  out, 
we  should  order  the  internal  use  of  sudorific  drinks,  composed  of 
saponaria  or  sarsaparilla  ; calomel,  aloes  and  cicuta  in  small  doses ; 
castor  oil ; the  mineral  waters  of  Plombieres,  of  Neris,  of  Luxeuil, 
or  Bourbon  les  Bains;  and,  lastly,  we  should  direct  the  patient  to  fix 
her  residence  in  a dry,  warm  situation;  she  should  also  be  directed  to 
wear  flannel  next  to  the  skin ; absolute  rest,  followed  by  moderate 
exercise,  a very  light  diet,  an  extreme  degree  of  sobriety  in  every 
sense  of  the  term,  could  not  but  add  to  the  efficacy  of  all  other  thera- 


# INFLAMMATION  OF  THE  OVARIA  AND  TUBES.  415 

peutical  agents,  on  which  rest  our  hopes,  if  not  of  curing,  at  least  of 
checking  the  progress  of  the  disease. 

The  course  to  be  followed  incase  of  the  inflamed  organ  becoming 
the  seat  of  a collection  of  pus,  would  be  the  same  as  that  pointed 
out  in  speaking  of  the  treatment  of  acute  ovaritis.  However,  we 
are  of  opinion  that  in  no  case  whatever,  should  resort  be  had  to  the 
extirpation  of  the  ovary,  as  has  by  some  writers  been  recommended. 

[I  fully  concur  with  the  author  in  his  disapprobation  of  operations  for  the 
extirpation  of  the  diseased  ovary;  and  I am  free  to  say,  that  I look  upon 
operations  for  the  extirpation  of  the  diseased  ovary,  as  not  to  be  justified  by 
the  most  fortunate  issue  in  any  ratio  whatever  of  the  cases.  1 apprehend 
the  ratio  of  success  hitherto  obtained,  as  not  justifying  the  operation.  In 
the  illustrations  of  some  of  the  principal  diseases  of  the  ovaria,  &c.,  by 
Ed.  S.  Seymour,  M.  D.,  Lond.,  1380,  the  author,  at  page  124,  makes  the 
following  judicious  remarks,  which  appear  to  me  quite  applicable  to  the 
increasing  disposition  to  prosecute  this  dangerous  surgery.  In  speaking 
of  the  operations  by  M.  Lizars,  and  other  surgeons,  Dr.  Seymour  was  not 
blinded  by  the  success — he  says,  “If  the  tumour  be  not  large,  and  the  wo- 
man’s health  unbroken,  she  may  live  many  years  ; as  long  as  is  allotted  to 
humanity,  in  the  enjoyment  of  a tolerable  existence.  If  the  health  be  much 
broken,  the  cure  of  so  large  a wound  in  a weakened  constitution  would  be 
difficult,  if  not  in  the  great  majority  of  cases  impossible.  If  connected  with 
scirrhus  in  other  parts  of  the  body  it  is  inadmissible  ; and  if  the  growth 
itself  be  of  the  nature  of  fungus  hematodes,  all  experience  tells  us,  that  should 
the  operation  be  survived  or  the  wound  healed,  the  disease  will  recur  in 
other  vital  organs  of  the  body.”  The  statistics  of  the  operation  show,  that 
out  of  some  sixty  or  seventy  operations,  there  have  been  lost  about  one-half 
of  the  subjects,  while  the  other  half  have  recovered — or,  in  other  words,  es- 
caped a present  death,  and  perhaps,  in  a few  instances,  recovered  a secure  and 
long  life.  Let  not,  however,  the  ardent  and  young  reader  be  infatuated 
with  even  such  success  as  this,  until  he  shall  first  have  satisfied  his  con- 
science and  judgment  as  to  the  grounds  upon  which  so  desperate  an  opera- 
tion is  instituted.  Let  him  lay  to  heart  Dr.  Seymour’s  remarks  just  quoted, 
and  let  him  assure  himself  that  persons,  and  many  persons,  indeed,  are 
known  to  carry  these  tumours  through  a long  existence,  with  even  very  little 
inconvenience,  and  that  in  some  cases  they  actually  diminish  in  size,  while 
the  inconveniences  attending  them  nearly  disappear.  Let  him  place  these 
facts  in  contrast  with  the  frighful  incision  extending  from  the  umbilicus  to 
the  pubis,  and  the  subsequent  handling,  pulling,  tying,  and  resection  of  the 
tumour  with  the  consequent  inflammation.  As  to  the  opening  of  the  abdo- 
men, in  cases  requiring  the  Cassarian  section,  I look  upon  that  operation, 
however  dreadful,  as  inevitable,  because  it  presents  the  only  hope  of  escape 
from  sudden  and  imminent  death — whereas,  in  the  case  of  a chronic  ovaritis, 
no  matter  what  may  be  the  particular  form  with  which  the  malady  clothes 
itself,  there  remains  a great  uncertainty  as  to  the  future  development  and 


416  INFLAMMATION  OF  THE  OVAFtIA  AND  TUBES.* 

influence  of  the  tumour.  I attended,  for  example,  a lady  in  several  suc- 
cessive labours,  while  she  laboured  under  a chronic  ovaritis,  accompanied 
with  immense  developments  of  the  abdomen,  from  fluid  in  the  ovarian  cyst. 
This  stale  of  things  continued  some  twelve  or  fifteen  years,  until  at  length 
finding  the  weight  too  considerable,  she  allowed  the  fluid  to  be  drawn  off  by 
an  operation  for  paracentesis  abdominis.  After  the  evacuation  of  the  sac, 
the  solid  portions  of  the  tumour  were  distinctly  felt  in  the  lower  and  left  side 
of  the  abdomen.  For  five  years  she  continued  gradually  to  fill  up  the  tu- 
mour again  until  she  was  again  tapped,  and  now  more  than  three  years  have 
elapsed,  and  she  enjoys  very  comfortable  and  active  health,  though  it  is  pro- 
bable that  within  another  year  she  may  require  a repetition  of  the  operation. 
It  is  quite  true,  that  the  operation  for  tapping  is  a dangerous  one,  particu- 
larly a first  tapping,  and  it  has  been  shown  by  FleetwoodChurchill,  of  Dublin, 
that  the  operation  of  tapping,  in  twenty  cases,  had  the  following  results : 
“ Thus,  fourteen  died  within  nine  months  after  the  first  operation,  four  of 
whom  survived  it  only  a few  days.  Of  the  remaining  six,  two  died  in 
eighteen  months,  and  four  lived  for  periods  varying  from  four  to  nearly 
nine  years.”  Dr.  0.  takes  this  table  from  Dr.  Southam’s  article  in  the 
Medical  Gazette.  It  ought  to  be  observed  that  six  of  these  persons  were 
over  forty  years  of  age,  and,  for  aught  we  know,  the  operation  may  have 
been  deferred  until  the  pressure  and  other  disturbing  influences  of  the  tumour 
had  utterly  ruined  the  constitution.  Indeed,  Dr.  Blundell’s  opinion,  that 
the  operation  should  be  performed  early,  if  at  all,  is  worthy  of  all  appro- 
bation. 

In  the  United  States,  the  extirpation  of  the  tumour  has  been  repeatedly 
effected  with  success,  as  may  be  seen  in  the  table  to  be  given  on  another 
page ; but  it  is  equally  true  that  frightful  disasters,  very  little  creditable  to 
the  healing  and  conservative  powers  of  surgery,  have  occurred;  disasters 
sufficiently  terrible  one  would  think,  forever  to  deter  from  engagement  in 
the  risks  of  reproducing  them.  It  ought  to  be  remarked,  that  the  ovary, 
when  once  fully  engaged  in  the  course  of  morbid  changes,  that  result  in  the 
development  of  what  is  called  ovarian  tumour,  has  already  cast  off,  so  to 
speak,  its  allegiance  to  the  common  government  of  the  economy.  Its  hyper- 
trophic, or  carcinomatous  or  hydropic  law  rules  it  supremely,  and  it  is  far 
from  being  a settled  point,  that  the  tying  up  of  the  root  or  pedicle  of  the 
tumour,  can  be  relied  upon,  for  the  total  extirpation  of  those  principles  of 
morbid  nutrition,  or  secretion  on  which  the  mass  depends  for  its  support 
and  growth.  In  case  a female  should,  by  fortunate  accident,  escape  with  life, 
the  smallest  remaining  portion  of  the  diseased  structure,  a leaven,  which 
leaveneth  the  whole  lump,  should  be  esteemed  capable  of  coming,  in  time, 
to  be  as  large  and  as  troublesome  as  before  the  extirpating  operation.  The 
Dublin  Journal  of  Med.  Science , for  July,  1844,  contains  a very  interesting 
paper  by  Dr.  Fleetwood  Churchill,  entitled  Notes  on  Ovariotomy.  Dr.  C. 
has  collected  the  resu  ts  of  sixty-six  cases,  in  which  the  diseased,  or  sup- 
posed diseased  ovary,  was  removed,  or  attempted  to  be  removed  by  the  sur- 


OVARIAN  TUMOUR. 


417 


geon.  He  gives  three  tabular  statements,  with  the  names  of  the  surgeons, 
the  size  of  the  incisions,  the  results,  and  the  character  of  each  tumour,  which 
we  subjoin  in  the  tables. 


Table  I. — Cases  of  Extirpation  of  the  Ovary. 


No.  and 

date. 

Operator. 

< 

Incision. 

Result. 

Character  of  disease. 

Adhesions. 

1, 

L’  Aumonier, 

4 inches, 

Recovered, 

Abscess  of  ovary. 

2,  1 80£ 

Dr.  McDowell, 

9 “ 

44 

Gelatinous  matter. 

3, 181€ 

4 

<t  u 

Long, 

“ 

Scirrhous  ovary. 

5, 

« « 

44 

44 

6, 

44  44 

44 

Died, 

7,  1821 

Dr.  N.  Smith, 

33 

3 inches, 

Recovered, 

Cyst,  fluid. 

Adhesions. 

8,  1825 

Mr.  Lizars, 

36 

Long, 

“ 

1 

9,  1825 

“ “ 

35 

“ 

Died, 

Adhesions. 

10, 

Dr.  A.  G.  Smith, 

30 

44 

Recovered, 

Cyst,  fluid, 

11, 

Dr.  Quittenbaum, 

44 

About  4 in., 

12, 1829 

Dr.  David  Rogers, 

“ 3 “ 

44 

Solid  and  fluid, 

Adhesions. 

13, 

Dr.  Granville, 

44 

44  44  44 

Died, 

14, 

Dr.  Chrysmer, 

47 

Long, 

44 

( Cartilaginous  and 
\ lardaceous  matter, 

Adherent.  1 

15, 

44  44 

38 

44 

Recovered, 

C Honey-like  and 

C green  sanies, 

16, 

“ Ci 

44 

Died, 

17, 

Dr.  Ritter, 

31 

44 

Recovered, 

Cyst,  fluid. 

18, 1836 

M r.  Kin?, 

57 

Short, 

“ 

44 

19, 1833 

Mr.  JeafFerson, 

44 

“ 

“ 

20, 

Mr.  DolhofF, 

23 

Long, 

Died, 

Cyst  and  fluid, 

Adhesions,  j 

21, 1836 

Mr.  West. 

“ 

Short, 

Recovered, 

22, 

a 

44 

“ 

« 

« 

23, 

“ 

24 

44 

Died, 

44 

24, 

« 

“ 

44 

Not  cured, 

“ 

25, 

Mr.  Hargraves, 

40 

«4 

44 

Multiloc.  cysts, 

Adhesions. 

26, 

Dr.  Clay, 

46 

27  inches, 

Recovered, 

Cysts,  solid  and  fluid, 

“ ( 

27, 

a 

67 

14  “ 

Ext.  adhes.  1 

28, 

39 

28  “ 

44 

44 

44 

29, 

u 

40 

14  « 

Died, 

44 

44 

30, 

44 

22 

14  « 

Recovered, 

44 

Adhesions,  j 

31, 

a 

40 

14  “ 

Died, 

None. 

32, 

a 

43 

14  « 

Recovered, 

44 

Ext.  adhes. 

33, 

“ 

59 

16  « 

Died, 

« 

34, 

“ 

46 

16  “ 

Recovered, 

“ 

“ 

35, 1840 

Mr.  B.  Philips, 

« 

2 “ 

Died, 

36,  1841 

Dr.  Stilling, 

“ 

6 « 

“ 

37,  1842 

Mr.  Walne, 

58 

Long, 

Recovered, 

44 

None. 

38, 1843 

“ 

57 

44 

44 

«( 

39, 

44 

21 

44 

Died, 

| 

40, 1843 

44 

20 

44 

Recovered, 

44 

a 

41,  1843 

Mr.  Morris, 

« 

44 

44 

42, 1843 

Mr.  Southam, 

“ 

“ 

44 

Cystic  sarcoma, 

“ 

43, 1843 

Dr.  F.  Bird, 

3 or  4 in., 

44 

Cyst  and  fluid, 

« 

44, 1844 

44 

“ 

44 

44 

Cysts  and  sol.  matter, 

« 

45, 

Dr.  Atlee, 

“ 

9 inches, 

“ 

44  44 

Adhesions. 

46, 

Mr.  Lane, 

« 

Long, 

44 

Cysts,  fluid 

None. 

47, 

Mr.  Key, 

19 

Died, 

“ 

48, 

Mr.  Greenhow, 

Mr.  B.  Cooper, 

29 

44 

44 

« 

49,  J 

32 

44 

44 

27 


418 


OVARIAN  TUMOUR. 


Table  II. — Cases  of  Ovarian  Disease  in  which  the  operation  could  not  he  completed. 


Date. 

Operator. 

Cause  of  failure. 

1 

Result.  j Incision.  j 

50, 

Dr.  M’Dowall, 

Adhesion  to  bladder 
and  uterus, 

[Recovered,  Long. 

1 51, 

Mr.  Ligars, 

Solid  and  very  vascular 
tumour, 

\ " « 

! 52, 1826, 

Dr.  Granville, 

Firm  adhesions, 

“ 6 inches. 

! 53, 

Dr.  Dieffenbach, 

Vascularity, 

“ Long. 

! 54,  1826,  ; 

Dr.  Martini, 

Solid,  fixed  tumour, 

jDied,  “ 

! 55, 

Anonymous, 

Fixed  tumour, 

| 56, 

Mr.  Dolhoff, 

“ 

j “ About  6 ins. 

1 57, 

Dr.  Clay, 

Extensive  adhesions, 

! “ (Long. 

58, 

1 i 

Mr.  Walne, 

u u 

(Recovered,  5 inches. 

1 

Table  III. — Cases  in  which  the  operation  failed  from  an  error  in  diagnosis. 


j Date. 

Operator. 

Result. 

Disease. 

1 59,  1823, 

Mr.  Lizars, 

Recovered, 

No  tumour  found. 

| 60,  1834, 

Mr.  Kins:, 

it  « 

I 61, 

Mr.  Dolhoff, 

Ct 

U ii 

62, 

Dr.  Clay, 

Died, 

Uterine  tumour. 

j 63, 

“ 

Recovered, 

Hydatid. 

. 64, 

U 

Died. 

Pelvic  tumour. 

1 65, 

«< 

Uterine  tumour. 

1 66, 

Mr.  Heath, 

“ 

ti  U 

After  making  the  above  statements,  Dr.  Churchill  sums  up  the  whole  in 
the  following  manner.  He  says  : “ 1.  The  entire  number  of  cases,  whether 
dropsy  or  scirrhus  of  the  ovary,  uterine  disease,  or  simulated  tumours, 
amounting  to  sixty-six  : of  these  forty-two  recovered,  and  twenty-four  died, 
or  about  one  in  two  and  three-fourths.” 

“Of  the  forty-nine  cases  in  which  the  ovary  was  extirpated,  sixteen  died, 
or  one  in  three  and  one-tenth.  Of  the  nine  cases  in  which  the  operation 
could  not  be  completed,  four  died,  or  one  in  two  and  one-fourth  ; and  of  the 
eight  cases  where  the  operation  was  unnecessary,  four  died,  or  one  in  two.” 

Dr.  Churchill,  among  his  conclusions,  at  p.  395,  says:  “ But,  bearing  in 
mind  these  difficulties,  and  making  allowance  for  these  draw-backs,  I think 
we  may  conclude  that  there  are  cases  in  which  the  operation  would  be  justi- 
fiable ; and  on  these  grounds, — we  find  the  general  opinion  is  against  the 
curability  of  the  disease  by  medical  means  ; — that  after  a time  the  patient 
will  die  from  local  disease,  or  accident,  or  constitutional  disturbance,  and 
that  mean  time  she  suffers  more  or  less  inconvenience;  that  tapping,  in 
almost  all  cases,  affords  but  temporary  relief ; and  that,  as  far  as  the  limited 
statistics  we  have  adduced  are  admissible  as  evidence,  it  is  attended  with 
great  danger;  i.  e.,  one  in  five  died  of  the  first  operation,  and  that  of  twenty 


OVARIAN  TUMOUR. 


419 


patients,  fourteen  (more  than  two-thirds)  died  within  nine  months  of  the 
first  tapping;  whilst  of  the  entire  number  of  those  who  underwent  the  ope- 
ration of  ovariotomy,  about  one-half  have  absolutely  recovered  so  far.” 

I have  thus  laid  before  the  reader,  the  results  obtained  by  Dr.  Churchill 
in  his  paper,  but  I wish  him  to  reflect  upon  the  value  of  statistical  exhibi- 
tions of  this  sort;  and  to  warn  him  against  the  seduction  of  statistics,  in 
cases  where  we  cannot  judge  of  the  necessity  or  the  propriety  of  the  risk  to 
which  the  patient  has  been  subjected.  If,  instead  of  ovariotomic  ones,  Dr. 
C.  had  given  us  the  statistics  of  one  hundred  cases  of  Caesarian  operations 
where  the  antero-posterior  diameter  of  the  superior  strait  wras  known  to  be 
not  more  than  two  inches,  and  the  foetus  alive,  there  would  be  no  hesitation 
in  agreeing  to  the  propriety  of  the  surgical  measure,  or  even  its  absolute 
necessity ; but  under  all  the  uncertainty  as  to  the  duration  of  life  in  chronic 
ovaritis,  I contend,  that  even  the  very  faint  praise  and  admission  of  the  ope- 
ration given  by  Dr.  Churchill,  are  indicative  rather  of  his  doubts  than  his 
approbation — his  fears  for  the  patient  rather  than  his  hope  for  the  victim. 

I freely  admit  that  where  the  tumour  has  attained  a certain  magnitude,  we 
have  no  hope  left  save  that  doubtful  one,  of  the  possibility  that  the  tumour 
shall  cease  to  augment,  as  often  happens  ; and  the  reasonable  expectation 
of  the  ability,  under  a wise  treatment,  to  retard  its  progress  and  obviate  its 
disturbing  force  in  the  economy. 

Seeing  that  it  is  pretty  well  understood  at  present,  that  the  catamenial 
office  depends  upon  the  periodical  evolution  of  the  Graafian  vesicle,  I beg 
leave  to  suggest  to  the  reader  the  propriety  of  giving  a due  share  of  atten- 
tion to  that  process  in  the  management  of  all  cases  during  the  mensual  life 
of  the  female,  that  have  not  gone,  as  to  volume,  beyond  any  reasonable 
hopes  of  control.  For  example,  a lady  from  a distant  city,  aged  about 
twenty-eight  years,  after  suffering  for  two  years  after  her  marriage  with 
very  intense  paroxysms  of  hysterical  passion  connected  with  irregular  and 
excessive  menstruation,  gave  birth  to  a child,  and  within  eighteen  months  to 
a second,  which  was  born  about  four  years  ago,  (1840). 

In  the  course  of  the  winter  of  1843,  she  discovered  a small  tumour  in  the 
lower  and  left  side  of  the  hypogastric  region.  It  appeared  upon  the  taxis  to 
be  some  two  and  a-half  inches  in  length  by  two  inches  in  breadth,  and  was 
movable  under  the  finger.  The  touch  and  the  surpubal  palpation,  led  me  to 
the  conclusion  that  the  tumour  was  a chronic  ovaritis  of  the  left  ovary.  It 
was  not  painful,  nor  did  it  visibly  affect  her  health  in  any  regard,  the  men- 
struation being  very  regular. 

I gave  a written  opinion  on  the  case,  upon  the  following  grounds : 

The  violent  hysterical  excitements  to  which  this  lady  was  long  subject, 
and  from  which  she  is  not,  even  now,  wholly  free,  derive  their  source  from 
the  ovaria  and  other  reproductive  organs.  As  she  menstruates  regularly,  it 
may  be  supposed  that  each  catamenial  period  will  be  one  of  affluxion 
towards  these  organs,  whose  hyperaemic  condition  cannot  fail  to  add  con- 


420 


OVARIAN  TUMOUR. 


siderable  force  to  the  morbific  tendencies  now  in  actual  exercise  in  the  ovary. 
Therefore,  let  attention  be  given  to  the  subduction  of  the  ovaric  excitements, 
especially  on  the  periodic  occasions.  If  the  mensual  periods,  which  may 
be  regarded  as  dangerous,  or  at  least  as  mischievous  crises,  can  by  any  art 
be  made  to  pass  by  with  the  least  possible  disturbance,  whether  local  or 
general,  the  tumour  may  be  expected  to  develop  itself  very  slowly,  or,  per- 
haps, even  to  retreat. 

To  this  end,  let  the  diet  be  carefully  regulated,  as  neither  too  spare,  nor 
too  nutritious — let  the  clothing  be  warm,  especially  about  the  pelvic  region 
and  the  lower  extremities,  with  a view  to  avoid  any  check  to  the  menstruae. 
Let  the  bowels  be  kept  in  a soluble  state.  Let  the  patient  take  a bath  at 
97°  three  times  a week,  and  go  from  the  bath  to  her  bed.  Leeches  suffi- 
cient to  take  three  or  four  ounces  of  blood  should  be  applied  to  the  left 
groin,  over  the  round  ligament,  four  or  five  days  before  each  menstrual 
period,  with  a view  to  obviate  the  then  hyperaemic  tendencies  of  the  ovarian 
stroma.  Let  her  not  leave  the  house  for  three  or  four  days  of  the  period  of 
return.  During  some  months  let  her  make  use  of  proper  doses,  three  to 
five  grains,  of  the  hydriodate  of  potassa,  thrice  a day. 

I hoped  by  such  measures  to  retard,  at  least,  the  growth  of  the  tumour ; 
and  I find  that  after  some  months,  in  which  the  course  has  been  faithfully 
carried  out,  there  is  a positive  diminution  of  the  size  of  the  diseased  mass. 
What  shall  be  the  result  of  the  case,  and  what  may  be  the  power  of  the 
treatment  to  control  or  modify  that  result,  must  be  left  to  time  to  disclose; 
but  I conceive  that  in  all  such  early  or  recent  cases  it  would  be  important  to 
fix  the  views  of  the  practitioner  upon  the  necessity  of  moderating  the  periodi- 
cal hyperaemia  of  the  reproductive  organs. 

I have  never  seen  ovarian  tumour  commence  after  the  cessation  of  the 
menses ; and  though  such  a case  may  have  happened,  it  appears  highly 
probable  that  the  disease  is  intimately  connected  with  the  mensual  function, 
which,  by  the  alternate  excitement  and  repose  of  the  vesicular  develop- 
ment, exposes  it  evidently  to  the  danger  of  inflammation,  acute  or  chronic, 
with  all  its  consequences  in  the  depravation  of  its  texture. — M.] 

OF  DROPSY  OF  THE  OVARIES,  AND  FALLOPIAN  TUBES. 

Chronic  inflammation  of  the  ovary  may  give  rise  to  various  altera- 
tions whose  existence  remains  for  the  most  part  unknown  until  dis- 
covered by  a post-mortem  examination.  Thus,  one  of  those  organs 
has  been  found  to  contain  a collection  of  hair,  or  portions  of  bones 
or  teeth,  which,  according  to  the  opinions  of  some  authors,  are  the 
relics  of  an  abortive  conception,  while  others  regard  them  as  evidence 
of  pregnancy  by  inclusion,  or  of  an  unnatural  nisns  formativus , inas- 
much as  similar  collections  have  been  found  in  various  other  parts 
of  the  body,*  even  in  the  male,  and  in  virgins  not  yet  arrived  at 

* Gordon  discovered  a tumour  within  the  cavity  of  the  thorax  containing  bones  and 
teeth,  surrounded  by  a substance  resembling  tallow.  Professor  Andral  discovered 


OVARIAN  DROPSY. 


421 


puberty,  as  in  the  cases  reported  by  Messrs.  Baillie,*  Seymour,!  Cru- 
veilhier,:}: and  Andral.§ 

The  preternatural  and  encysted  products  in  question  have  been 
very  often  met  with;  as  they  never  grow  to  a very  large  size,  their 
existence  is  rarely  suspected  during  the  life  of  the  patient ; besides, 
it  is  probable  that  they  are  much  more  frequently  the  causes  than 
the  effects  of  ovaritis.  That  disease,  when  chronic,  on  the  contrary, 
much  more  generally  ends  in  scirrhous  indurations,  in  encephaloid 
softening,  in  tumours,  either  homogeneous  or  filled  with  hydatids, 
and  especially  in  an  encysted  tumour,  known  as  dropsy  of  the  ovary, 
of  which  we  shall  proceed  to  treat. 

This  kind  of  dropsy  is  not  only  the  most  common  of  the  encysted 
dropsies,  but  also  the  most  ordinary  form  of  ovarian  disease,  and 
one,  indeed,  to  which  the  female  is  most  liable.  Though  it  be  proba- 
ble that  the  formation  of  the  serous  cysts  which  constitute  the  dis- 
ease, always  takes  place  in  the  same  manner,  it  has  been  divided 
into  several  varieties,  as,  1st.  Uni-locular  cysts , that  is,  where  the 
ovary  is  converted  into  a single  sac,  which  is  generally  polished  on 
the  external  surface,  of  a globular  shape,  though  sometimes  multi- 
lobular or  pyriform,  and  attaining  so  great  a size,  in  some  instances, 
as  to  distend  the  abdomen  like  a common  ascites.  2d.  Multi-locular 
cysts , composed  of  a number  of  cells,  each  communicating  with  the 
others,  or  else  of  several  groups  of  distinct  lodges,  though  their  con- 
stituent parts  are  connected  together.  The  cysts  comprised  under 
this  variety  are  mostly  lumpy  on  the  surface.  3.  Multiple  cysts , or 
such  as,  though  distinct  the  one  from  the  other,  yet,  by  their  aggre- 
gation, make  up  the  tumour.  Each  one  of  these  cysts  may  be  either 
uni-locular  or  multi-locular.  There  is  generally  one  principal  cyst 
which  effaces,  in  a manner,  all  the  rest ; so  that  the  external  surface 
of  the  mass  is  smooth,  instead  of  being  lumpy.  4th.  Areolar  cysts , 
in  which  the  ovarian  tissue  is  divided  into  areolae,  or  cells,  containing 
a peculiar  gelatiniform  matter.  According  to  M.  Cruveilhier,  this 
variety  of  the  multi-locular  cyst  is  like  the  areolar  cancer,  especially 
the  areolar  cancer  of  the  stomach,  from  which  it  differs  only  in  the 
greater  size  of  the  meshes. 

5.  Acepkalocyst  cysts , which  rarely  become  as  large  as  the  other 
serous  cysts  above  mentioned,  and  are,  moreover,  distinguished  espe- 
cially by  containing  hydatids,  which  we  need  not  again  advert  to. 

The  texture  of  an  ovarian  cyst  is  commonly  fibrous,  and  contains 
blood-vessels.  In  some  instances,  it  is  found  to  be  very  thin ; in 

another  between  the  laminae  of  the  mesentery  in  a negro  woman  ; the  tumour,  which 
was  as  large  as  a festal  head,  contained,  in  the  midst  of  a quantity  of  fatty  matter,  a 
collection  of  hair,  some  of  which  was  isolated,  and  the  rest  in  bunches.  It  should 
however,  be  observed  that  these  preternatural  collections  are  most  frequently  met  with 
in  the  ovaries,  and  that  here,  as  well  as  elsewhere,  they  are  surrounded  by  a quantity 
of  steatomatous  matter,  as  is  shown  in  the  cases  related  by  Portal,  Meckel,  Logger, 
Murat,  Cruveilhier,  Paul  Marshall,  Andral  and  others. 

* Anat.  Pathol,  p.  319. 

f Illustrations,  &c.  of  Diseases  of  the  Ovaries,  83. 

i Essai  sur  l’Anat.  pathol.,  t.  ii.  180. 

§ Precis  d’Anat.  pathol.,  t.  ii. 


422 


OVARIAN  DROPSY. 


others,  on  the  contrary,  it  is  very  thick,*  and  has  a steatomatons 
appearance.  Its  internal  surface,  which  may  happen  to  be  smooth, 
is  more  frequently  found  to  be  rugous  and  uneven.  According  to 
Hoopert  and  M.  Cruveilhier,f  (loc.  cit.,)  the  walls  of  the  sac  are  some- 
times observed  to  be  nodose,  and  to  contain  laminae  of  cartilage  and 
even  of  bone. 

The  fluid  contained  in  the  cyst  is  generally  serous ; it  may  be  lim- 
pid, ropy,  like  albumen,  of  a gelatinous  appearance,  sanguineous, 
purulent,  of  a chocolate  colour,  or  like  coffee  grounds,  &c. 

In  the  multi-locular  dropsies,  the  fluid  may  differ  in  the  different 
cells,  as  to  its  colour  and  its  nature,  and  may  even  undergo  putrefac- 
tive decomposition,  giving  rise  to  gases,  whose  escape  through  the 
trocar-canula  leads  the  surgeon  to  suppose  that  it  communicates  with 
an  intestine. 

The  quantity  of  fluid  contained  in  a dropsical  ovary  varies  very 
much  in  different  specimens.  At  first,  the  morbid  accumulation  of 
serosity  is  scarcely  perceptible;  but, in  a more  advanced  stage,  it  may 
be  very  considerable.  Morand  had  an  ovarian  cyst  which  held  ten 
pints,  and  he  mentions§  that  Dr.  Duret,  of  Vitry-le-Frangais,  reported 
to  the  Academy,  in  1740,  the  history  of  a case  of  ovarian  dropsy,  in 
which  the  cyst  held  fifty  pints:  it  had  distended  the  abdomen  so 
much  that  the  woman  was  obliged  to  tie  her  petticoat  four  finger 
breadths  below  the  axilla.  In  fine,  according  to  Munro,||  Wepfer, 
and  other  authors,  the  weight  of  the  serum  has  been  known  to 
amount  to  one  hundred  and  ten  and  to  one  hundred  and  twenty 
pounds. 

Where  the  disease  is  already  of  old  standing,  both  of  the  ovaries 
are  generally  found  to  be  affected;  but  the  disease,  which  began  first 
upon  one  side,  is  always  less  forward,  and  the  tumour  smaller  than 
on  the  side  where  the  lesion  first  commenced.  Under  these  circum- 
stances, the  belly  appears  to  be  uneven,  lumpy,  and,  in  many  in- 
stances, divided  into  different  and  distinct  lobes,  just  as  happens 
where  a scirrhous  degeneration  has  taken  place,  or  where  the  ovary 
is  divided  into  several  cysts.  These  multiple  cysts,  which  are  per- 
haps more  common  than  single  cysts,  exhibit  a great  variety  of  cha- 
racter. Sometimes  the  tumour,  which  is  susceptible  of  acquiring  a 
very  large  size,  is  divided  into  two  or  three  portions,  unequally  deve- 
loped. Sometimes,  on  the  other  hand,  the  size  of  each  sac  is  very 
small ; but,  as  remarked  by  Messrs.  Munro,  Cruveilhier,  Delpech, 
Strambio,  Andral,  &c.,  their  slight  development  is  generally  compen- 
sated for  by  their  great  number,  which  is  very  considerable  in  some 
of  the  specimens.  It  should  be  added,  that  in  these  cases  of  multiple 
ovarian  cysts,  the  front  one  is  almost  always  the  largest;  that  is  to 

* Morand  (Mem.  de  I’Acad.  de  Med.,  t.  ii.  p.  426)  speaks  of  two  empty  cysts,  one  of 
which  weighed  fourteen,  and  the  other  twenty-seven  pounds. 

t The  Morbid  Anat.  of  the  Uterus,  pi.  xx.,  1832. 

* Ratio  Medendi,  t.  ii.  p.  259. 

§ Mem.  de  l’  Acad,  de  Chirurg.,  t.  ii.  p.  457. 

!|  Monro,  Essay  on  Drops}',  p.  228;  and  J.  I.  Wepfer,  Observ.  Anat.  ou  Cadav., 
&c.,  1658. 


OVARIAN  DROPSY. 


423 


say,  the  most  voluminous  and  heaviest  cyst  of  the  tumour  is  dragged 
in  front  of  the  others  by  its  own  weight. 

The  causes  and  the  mode  of  development  of  ovarian  dropsies  are, 
as  yet,  but  little  known.  Whether  the  disorder  depends  on  the  new  for- 
mation of  a cyst,  created  de  novo  within  the  ovary,  under  the  influence 
of  some  inappreciable  morbid  state,  or  a cancerous  state,  as  supposed 
by  many  writers,  as  Ledran,  Delpech,  ( Joe . cit.,  p.  214,)  and  M.  Cru- 
veilhier,  who  compares  the  multi-locular  cyst  to  the  areolar  cancer ; 
or,  whether  the  encysted  tumour  results  from  the  accumulation  of  a 
serous  fluid,  in  one  or  more  ovarian  vesicles,  the  first  origin  of  the 
evil  ought,  in  our  opinion,  to  be  always  referred  to  a chronic  inflam- 
mation. What  is  more  certain,  as  to  the  etiology  of  ovarian  dropsy, 
is  this,  viz.,  that  it  is  never  found  to  manifest  itself,  except  at  those 
periods  of  life  during  which  the  genital  organs  are  possessed  with 
their  highest  degree  of  activity,  which  is  from  the  age  of  twenty  years 
to  forty-five  years.  It  is  proper  to  remark,  however,  that  although 
the  disease  has  been  met  with  in  girls  not  arrived  at  puberty,  and  in 
women  beyond  the  change  of  life , such  as  have  been  the  subjects  of 
the  sexual  embrace,  and  particularly  women  who  have  borne  chil- 
dren, are  much  more  subject  to  the  disease  than  virgins  and  women 
who  have  never  conceived. 

Among  the  determining  causes  of  ovarian  dropsy,  have  been 
classed  all  the  causes  we  have  mentioned  as  giving  rise  to  ovaritis  ; 
such  as  external  violence,  a blow, a fall  upon  the  hypogastric  region; 
indeed,  all  the  various  abusive  causes  of  irritation  and  excitement  of 
the  genital  system,  the  chief  of  which  is  masturbation,  and  other 
indecent  manoeuvres,  which  females  rarely  confess  to  their  physi- 
cians. However,  it  must  be  admitted  that  the  disorder  is  often  deve- 
loped without  any  distinguishable  provocation. 

The  symptoms  of  this  affection  are  very  obscure  at  first.  As  in 
the  incipient  stage  of  its  existence,  it  causes  very  little  inconvenience, 
and,  moreover,  is  developed  very  slowly;  the  female  who  is  attacked 
with  it  pays  very  little  attention  to  it,  and  many  of  them  attribute 
their  feelings  to  an  incipient  pregnancy ; a mistake  the  more  easily 
made,  since  both  the  conditions  are  marked  by  the  same  symptoms. 
For  example,  the  gradual  enlargement  of  the  abdomen,  as  well  as  of 
the  breasts,  the  suppression  of  the  menses,  the  vomiting,  the  disgust, 
the  queer  appetite,  &c.,  as  they  may  be  met  with  in  ovarian  dropsy, 
as  well  as  in  pregnancy,  may  contribute  to  deceive  the  woman,  and 
mislead,  at  the  same  time,  the  physician,  who  feels  secure,  even 
while  under  a great  error. 

Before  the  development  of  the  tumour  becomes  sufficiently  con- 
siderable to  admit  of  its  becoming  sensible  to  the  external  touch,  the 
woman  feels  a dull,  deep-seated  and  permanent  pain  in  one  of  the 
iliac  regions,  with  a feeling  of  weight  in  the  corresponding  hip  and 
thigh.  The  progress  of  the  tumour  is  generally  very  slow  ; indeed, 
it  sometimes  requires  several  years  to  make  it  perceptible  to  the  ex- 
ternal touch ; and  such  is  the  depth  of  the  situation  of  the  ovary, 
and  so  great  is  the  thickness  of  the  abdominal  parietes,  that  it  must 
have  attained  a considerable  magnitude  before  it  can  be  externally 


424 


OVARIAN  DROPSY. 


felt.  When  it  does  become  large  enough,  a tumour  may  be  felt  near 
one  of  the  groins,  which,  provided  it  has  contracted  no  adhesions 
with  the  adjacent  parts,  generally  projects  most  on  the  side  on  which 
the  patient  lies.  As  this  tumour  may  be  globose,  circumscribed,  even, 
or  lumpy,  indolent  or  painful,  it  is  often  a difficult  matter  to  decide 
whether  it  be  a scirrhous,  an  extra-uterine  pregnancy  or  an  ovarian 
cyst.  Though  the  fact  of  fluctuation  in  the  tumour  may  be  held  to 
dissipate  all  doubt  as  to  its  nature,  the  absence  of  the  fluctuation  is 
not  always  to  be  taken  as  proving  the  negative,  as  the  matter  of  the 
cyst  maybe  thick  or  gelatinous;  a mistake  is  so  much  the  more 
easily  made,  inasmuch  as  a dropsy  of  the  ovary  often  coincides  with  a 
scirrhous  state  of  the  same  organ.  It  is,  in  fact,  the  frequent  coinci- 
dence of  these  two  affections,  that  has  led  different  authors  to  ima- 
gine that  the  ovarian  cyst  is  always  complicated  with  a scirrhous 
state  of  the  organ.  In  some  of  the  cases,  so  slow  is  the  progress  of 
the  disorder,  that  many  years  have  elapsed  before  the  tumour  has 
acquired  any  considerable  size.  In  these  instances  the  women  retain 
their  fresh  colour  and  their  embonpoint  for  a long  time,  and  appear 
to  be  in  the  enjoyment  of  all  the  attributes  of  a most  perfect  health  ; 
some  of  them,  in  whom  only  one  ovary  is  affected,  have  been  known 
to  conceive  and  bear  children  with  safety.  It  generally  happens 
that  as  long  as  the  cyst  continues  to  be  of  inconsiderable  size,  and 
particularly  where  only  one  of  the  ovaries  is  affected,  the  functions 
of  the  pelvic  viscera,  such  as  the  excretion  of  the  urine  and  of  the 
stool,  and  the  mensual  evacuation,  continue  to  be  performed  with 
great  regularity.  On  the  other  hand,  when  the  encysted  tumour 
begins  to  attain  a certain  magnitude,  the  viscera  in  proximity  with  it 
being  displaced,  and  more  or  less  inflamed  by  the  pressure,  contract 
adhesions  with  each  other,  as  well  as  with  the  tumour  itself.  The 
painful  dragging  sensations  felt  by  the  patient  upon  any  change  of 
position,  or  on  turning  upon  the  side  opposite  to  the  diseased  one, 
are  the  indicias  of  the  morbid  adhesions  that  bind  the  abdominal 
viscera  together  with  the  cyst.  The  womb  may  also  suffer  various 
sorts  of  displacements ; sometimes  it  is  found  pressed  over  to  the  side 
of  the  pelvis  ; at.  others  it  is  deeply  depressed  within  the  excavation 
by  the  weight  of  the  tumour  resting  on  the  fundus  uteri ; the  abdo- 
men, which  is  most  prominent  on  the  side  first  affected,  most  generally 
allows  us  to  detect  the  existence  of  a dropsical  fluctuation,  though 
the  fluid  may  as  yet  occupy  only  a portion  of  the  swelling. 

Where  the  cyst  has  become  large  enough  to  push  the  bowels  and 
the  stomach  upwards  against  the  diaphragm,  and  thrusts  the  latter 
upwards  into  the  confines  of  the  thorax,  the  powers  of  digestion  are 
interfered  with,  and  the  respiration  is  embarrassed.  Obstinate  con- 
stipation supervenes ; the  fluctuation  in  the  abdomen  becomes  more 
evident,  and  the  fluid,  which  now  appears  to  occupy  the  whole 
capacity  of  the  belly,  often  leads  to  a belief  that  the  case  is  one  of 
ascites.  In  certain  instances  the  tumour,  after  having  attained  this 
great  degree  in  its  development,  becomes  stationary  as  to  its  progress. 
Sabatier  dissected  several  subjects  in  which  tumours  of  this  sort  had 
continued  during  a term  of  forty-five  and  even  fifty  years,  without 


DROPSY  OF  THE  OVARIUM. 


425 


any  evident  morbid  influence  on  the  general  health  of  the  individu- 
als. Notwithstanding  the  abdomen  was  enormously  large,  their  vital 
powers  had  been  maintained,  because  the  functions  of  their  abdomi- 
nal viscera  had  been  executed  without  too  much  interference  of  the 
tumour.  It  must  be  said,  however,  that  where  the  cyst  is  very  large, 
the  patient,  as  a general  rule,  is  incapable  of  much  motion,  and  the 
pressure  it  exerts  on  the  viscera  is  sometimes  so  great  that  their 
functions  are  either  entirely  disordered,  or  more  or  less  interrupted. 
Lastly,  let  us  add,  that  a distressing  dyspnoea,  an  imminent  danger  of 
suffocation,  an  ischuria  .renalis,  painful  and  obstinate  constipation, 
and  in  the  end,  a hectical  form  of  fever,  are,  for  the  most  part,  the 
sad  forerunners  of  the  approaching  dissolution  of  the  patient. 

The  diagnosis  of  dropsy  of  the  ovary  is  not  always  very  easily 
settled,  because  the  disorder  exhibits  certain  general  phenomena  and 
local  symptoms,  that  are  more  or  less  similar  to  those  of  simple  preg- 
nancy, of  extra-uterine  pregnancy,  as  was  the  case  in  a sample  that 
fell  under  the  notice  of  Merklin,  of  ascites,  of  hydrometra,  &c. 

It  may  be  ascertained  that  the  increased  size  of  the  abdomen  is 
due  to  the  dropsical  state  of  the  ovary  and  not  to  a state  of  pregnancy, 
by  recollecting  that  in  the  case  of  an  ovarian  cyst,  the  tumour  forms 
slowly,  and  commences  at  first  on  one  side  only,  that  it  is  circum- 
scribed, often  having  an  irregular  shape,  lumpy,  and  exhibiting  cer- 
tain harder  points  on  its  surface,  and  particularly  near  its  base ; that 
by  means  of  auscultation,  which,  in  such  a case,  is  merely  negative, 
that  is  to.  say,  without  any  fetal  pulsations,  or  placental  sounds,  we 
most  generally  may  discover  gurgling  sounds  at  different  points  of  the 
tumour,  which  principally  occupies  one  side  of  the  abdomen  ; in  fine, 
that  the  fluctuation  , which,  in  a majority  of  the  cases,  may  be  ascer- 
tained to  exist,  is  confined  within  the  boundaries  of  the  tumour.  By 
the  vaginal  touch  the  cervix  uteri  is  found  to  be  small  and  thin, 
while  the  os  tincae  is  a narrow,  regular,  transverse  orifice,  yet  by 
pressing  upon  the  hypogastrium,  we  do  not  eause  it  to  move  at  all. 
Attention  should  also  be  paid  to  all  the  circumstances  attending  the 
progress  of  the  abdominal  swelling,  nor  should  we  forget  that  for  the 
most  part,  the  menses  are  suspended  in  dropsy  of  the  ovary  as  they 
are  in  pregnancy,  and  that  in  either  case,  a woman  may  exhibit 
general  or  sympathetic  phenomena  having  the  closest  analogy  to 
each  other.  The  age  of  the  patient,  a state  of  barrenness  protracted 
through  many  years  of  the  married  life,  the  unmarried  state  of  the 
woman,  and  her  social  position,  may,  when  considered  in  conjunction 
with  the  other  symptoms,  lead  to  the  rejection  of  the  idea  of  preg- 
nancy. It  should  also  be  remarked  that  the  absence  of  the  sponta- 
neous motions  of  the  child,  and  the  persistence  of  the  abdominal  dis- 
tension to  a period  beyond  the  term  of  utero-gestation,  may  assist  in 
putting  an  end  to  all  doubt  as  to  the  questions  of  normal  pregnancy 
or  extra-uterine  pregnancy. 

To  distinguish  betwixt  an  ovarian  dropsy  and  a case  of  ascites, 
we  should  not  forget  that  in  the  latter  disease,  the  patient’s  constitu- 
tion generally  exhibits  marks  of  languor  and  atony  pervading  the 
entire  organism,  such  as  excessive  paleness,  bloating  of  the  face,infil- 


426 


DROPSY  OF  THE  OVARIUM. 


tration  of  the  lower  limbs,  and  not  unfrequently  of  the  external  geni- 
tals also.  In  ascites,  the  discharge  of  urine  is  generally  diminished 
in  quantity,  while  in  case  of  an  ovarian  cyst,  the  amount  of  urine 
produced  appears  to  be  more  considerable  than  is  usual,  especially 
where  the  tumour,  by  compressing  the  urinary  bladder,  gives  rise  to 
an  uneasy  sensation  that  excites  the  woman  to  more  frequent  efforts 
to  discharge  its  contents.  Nevertheless,  it  does  sometimes  happen 
that  too  strong  a compression  of  the  bladder  of  urine  may,  in  ovarian 
dropsy,  produce  a complete  incontinence,  which  constitutes  one  of 
the  most  distressing  complications  of  the  malady.  In  ascites,  the 
swelling  of  the  belly  takes  place  more  rapidly  and  in  a more  uniform 
manner,  and  the  fluctuation  is  perceptible  in  every  part  of  the 
tumour.  In  dropsy  of  the  ovarium,  on  the  contrary,  it  is  dull  and 
circumscribed,  the  shape  of  the  abdomen  is  always  less  regular,  its 
growth  does  not  proceed  in  every  dimension  at  one  and  the  same 
time,  and,  lastly,  the  tumour  which  seems  to  come  up  from  within 
the  pelvis  is  always  largest  at  the  side  on  which  it  first  made  its 
appearance. 

[I  do  not  think  that  practice  will  always  prove  this  diagnostic  sign  to  be  a 
dependable  one,  since  the  tumour,  provided  it  have  a long  and  very  flexible 
pedicle,  may,  by  the  italic  sigma  of  the  colon,  be  pressed  towards  and  kept 
on  the  right  side,  even  though  it  may  come  from  a depravation  of  the  structure 
of  the  left  ovary. — M.] 

We  add,  that  as  dropsy  of  the  ovarium  is  formed  more  slowly  than 
the  dropsy  of  an  ascites,  the  patient  is  less  incommoded  by  it  in  the 
early  stages,  and  some  of  them  preserve  their  embonpoint,  and  their 
healthy  complexion  for  a long  time,  a circumstance  which  does  not 
hold  good  as  to  ascites,  which  is  generally  accompanied  with  all  the 
marks  of  a cachectic  state,  and  of  a general  hydropic  diathesis,  and 
particularly  with  oedema  of  the  lower  extremities.  The  infiltration 
that  is  now  and  then  observed  as  a consequence  of  ovarian  dropsy, 
is  generally  confined  to  the  thigh  corresponding  to  the  side  affected, 
which  may  likewise  be  the  seat  of  a feeling  of  numbness,  arising 
from  the  pressure  of  the  tumour  upon  the  crural  nerves  and  blood- 
vessels. The  chief  difference  between  ascites  and  ovarian  dropsy  is 
that  the  latter,  like  a hydrocele,  is  a purely  local  disorder. 

Where  a peritoneal  dropsy  exists  at  the  same  time  with  a dropsy 
of  the  ovary,  we  discover,  by  means  of  palpation,  a stratum  of  fluid 
separating  the  abdominal  walls  from  a tumour  lying  free  within  the 
peritoneal  cavity.  By  moderate  pressure  we  can  generally  succeed 
in  pressing  aside  the  serosity  with  the  hand,  and  thus  get  down  to 
the  real  tumour  itself,  and  clearly  appreciate  its  resistance,  size  and 
shape. 

Where  the  abdominal  walls,  from  being  distended  both  by  an 
encysted  ovarium  and  a peritoneal  dropsy,  have  yielded  as  far  as 
their  natural  elasticity  will  admit  of,  it  occasionally  happens  that  a 
portion  of  the  ovaric  tumour  forms  a hernial  protrusion.  l)r.  Iluguier, 
upon  the  autopsy  of  a female  who  died  in  1830,  at  the  Hospital  St. 


DROPSY  OF  THE  OVARIUM. 


427 


Louis,  of  an  ovarian  dropsy,  complicated  with  ascites,  found  a cyst  of 
the  ovary  larger  than  a man’s  head,  presenting  the  following  appear- 
ances-: the  tumour  was  multilobular  and  divided  into  four  portions; 
the  first,  internal  and  inferior,  filled  up  the  pelvic  excavation ; the 
second,  anterior  and  internal,  occupied  the  corresponding  part  of  the 
abdomen;  the  third,  superior  and  external,  whose  summit  touched 
the  under  surface  of  the  right  lobe  of  the  liver,  had  detached  the  peri- 
toneum from  the  whole  of  the  right  costo-iliac  region,  and  the  infe- 
rior part  of  the  anterior  paries  of  the  abdomen,  and  engaged  itself 
within  the  crural  canal,  not  only  its  internal  portion  where  the  lym- 
phatic vessels  pass  and  where  hernias  are  formed,  but  even  through- 
out the  whole  length  of  the  canal, folio  wing  the  aponeurotic  expansion 
furnished  to  the  thigh  by  the  fascia  iliaca.  This  portion  of  the 
tumour,  which  contained  nothing  but  serum,  was  three  inches  long 
by  two  inches  in  breadth,  and  situated  behind  and  outside  of  the 
crural  vessels.  It  is  only  necessary  to  know  that  a crural  hernia  of 
an ' ovarian  cyst  is  a possible  case,  in  order  to  avoid  the  errors  of 
diagnosis  that  such  a displacement  might  give  rise  to.  Lastly,  we 
remark  that  the  general  symptoms  and  sympathetic  and  hysterical 
phenomena  that  accompany  most  of  the  maladies  of  the  womb  and 
ovaries,  ought,  likewise,  to  aid  us  in  discriminating  betwixt  an 
ovarian  dropsy  and  the  other  serous  collections  of  the  abdominal 
cavity. 

The  prognosis  of  the  disease  under  consideration  is  always  unfa- 
vourable, especially  when  complicated  with  scirrhus  of  the  ovarium, 
with  ascites,  a general  dropsy,  or  hydrothorax.  Notwithstanding 
some  women  have  been  found  to  attain  an  advanced  age,  though 
long  afflicted  with  dropsy  of  the  ovary,  they  almost  all  fall  victims  to 
the  progress  of  their  malady,  either  from  a rupture  of  the  cyst,  whose 
fluid  is  effused  into  the  cavity  of  the  belly,  giving  rise  to  a mortal 
peritonitis,  or  from  the  disorders  and  disturbances  produced  by  the 
pressure  of  the  tumour  upon  the  abdominal  viscera,  or,  finally,  from 
the  accidents  which  very  frequently  result  from  the  operations  re- 
quired in  order  to  evacuate  the  fluid  or  remove  the  diseased  organ. 
It  sometimes  happens  that  the  rupture  of  the  tumour  is  favourable  to 
the  patients,  because  the  serous  fluid  has  been  discharged  into  the 
cavity  of  some  neighbouring  viscus  which  has  been  perforated  simul- 
taneously with  the  cyst*;  Denman*  saw  it  escape  by  the  rectum ; 
Madame  Boivin,t  by  the  vagina,  in  two  cases ; Monro, % once,  by  the 
same  route,  and  again,  through  the  groin;  and  Mead  and  Locock§ 
through  the  umbilicus. ||  Denman’s  patient,  one  of  Madame  Boivin’s, 
and  the  one  of  which  Mead  speaks,  were  entirely  cured ; the  others 
relapsed,  and  death  occurred  some  time  after.  Sometimes,  after  rup- 
ture of  the  cyst,  the  effusion  into  the  abdominal  cavity  has  been 

* Med.  and  Physic.  Journal,  vol.  ii.  p.  20. 

f Recherches  sur  l’avortement,  etc.,  pp.  103,131. 

± Edinburgh  Essays,  vol.  vi.  p.  387. 

§ Illustrations,  etc.  of  the  Principal  Diseases  of  the  Ovaria,  p.  53. 

||  Doctor  Grenville  (Med.  Physic.  Journ.,  1822),  has  published  a case  of  encysted 
tumours  of  the  right  ovarium,  some  of  which,  as  large  as  the  head  of  a fetus,  opened 
and  gave  issue  to  purulent  matters  through  an  ulceration  in  the  walls  of  the  abdomen. 


428 


DROPSY  OF  THE  OVARIUM. 


reabsorbed,  and  a complete  cure  effected.  Doctor  Seymour  (loc.  cit., 
p.  55,)  quotes  from  Blundell,  a case  in  which  absorption  took  place, 
after  effusion  into  the  abdomen,  though  the  rupture  of  the  ovarian 
cyst  had  been  occasioned  by  a fall.  We  shall  conclude  our  remarks 
upon  the  prognosis  of  dropsy  of  the  ovarium,  by  adding  that  the  dis- 
ease ought  to  be  ranked  amongst  those  whose  progress  may  some- 
times be  retarded,  but  whose  complete  cure  can  rarely  be  obtained. 
It  is  wrong,  however,  to  pronounce  an  unfavourable  prognosis  too 
soon ; for  Portal,*  Petit  Radel,t  M.  Nauche,f  Seymour  (loc.  cit.,  pp. 
93, 116  and  119,)  and  several  other  practitioners,  cite  several  cases  of 
cure  obtained  by  various  means,  which  we  shall  point  out. 

The  treatment  of  dropsy  of  the  ovarium  is  far  from  having  been 
determined  with  precision;  for  whatever  be  the  therapeutical  methods 
that  have  been  employed,  the  examples  of  failure  are  infinitely  more 
numerous  than  those  of  success.  Thus  purgatives ; emetics ; sudor  i- 
fics  ; diuretics;  sialagogues;  simple,  salt,  and  sulphurous  baths ; per- 
cussion and  compression  of  the  abdomen ; revellents  and  resolvents, 
both  internal  and  external ; puncture ; incision  and  extirpation  of  the 
tumour,  and  a crowd  of  empirical  remedies,  have  been,  turn  by  turn, 
employed,  and  all  followed  by  rare  and  isolated  cases  of  cure. 

Though  we  ought  not  to  place  much  confidence  in  the  means  de- 
rived from  medicine  strictly  so  called,  we  are  of  opinion  that  they 
ought  always  to  be  employed  before  recurring  to  those  afforded  as 
by  surgery.  Consequently,  sudorifics  ought  first  to  be  prescribed, 
for  example,  guaiac,  sarsaparilla,  and*  vapour-baths;  resolvents, 
among  others  mercurial  frictions,  successfully  employed  by  Clarke 
and  M.  Nauche ; those  of  hydriodate  of  potash  with  the  internal  use 
of  iodine  in  small  doses ; sea-bathing,  or  salt-water  baths,  from  which 
M.  Laennec,  of  Nantes,  says  he  has  obtained  most  excellent  effects : 
the  thermal  baths  of  Aix,  in  Savoy,  or  of  Barege ; antimonial  fric- 
tions, cauteries,  moxas,  and  blisters  applied  upon  the  abdomen. 
Diuretics,  such  as  squills,  nitre,  etc.,  which,  according  to1  Haller, § 
were  usefully  employed  by  Willis  ; a decoction  made  from  ashes  in 
the  proportion  of  a handful  to  a quart  of  water,  which  Petit  Radel 
(loc.  cit.,)  employed,  and  from  which  he  obtained  a cure,  after  having 
punctured  the  ovarian  cyst ; lastly,  purgatives  in  divided  doses ; for 
instance,  aloes,  rhubarb,  croton  oil,  calomel  combined  with  Castile 
soap,  and  sulphate  of  potash,  etc.,  are  other  means  which,  in  conjunc- 
tion with  abstinence  and  compression  of  the  abdomen,  may  be  pre- 
scribed at  the  commencement  of  the  disease,  for  the  purpose  of 
assisting  the  absorption  of  the  fluids  at  first  small  in  quantity. 

When  the  cause  of  the  disease  can  be  discerned,  we  must  endea- 
vour to  remove  it  as  early  as  possible.  If  it  have  occurred  after  a 
blow,  a fall  or  some  engorgement  resulting  from  inflammation,  we 
should  resort  to  the  use  of  baths  and  to  general  and  local  bleedings, 
especially  if  the  woman  be  of  strong  constitution.  Should  the  dis- 

* Observat.  sur  la  nature  etle  traitement  de  l’hydropisie,  1. 1.  p.  15. 

j- Encyclopedic  methodique,  chirurgic.,  t.  ii.  p.  134. 

\ Maladies  des  femmes,  t.  i.  p.  174. 

§ Disputationes  Morborum,  vol.  iv. 


DROPSY  OF  THE  OVARIUM. 


429 


ease  have  followed  suppression  of  the  menses  or  of  a haemorrhoidal 
flux,  appropriate  means  for  restoring  these  discharges  ought  to  be 
directed.  Lastly,  when  ovarian  dropsy  has  followed  the  disappear- 
ance of  a cutaneous  eruption,  of  gout  or  rheumatism,  etc.,  the  irritation 
must  be  restored  as  soon  as  possible  to  the  place  it  primarily  occu- 
pied, and  then  remedies  proper  for  the  treatment  of  these  different 
diseases  should  be  resorted  to. 

When  these  various  therapeutical  means  fail,  which,  unfortunately, 
is  generally  the  case,  we  may  resort  to  the  operation  of  tapping,  in 
order  to  remove  the  fluid  contained  in  the  cyst.  This  operation, 
which  is  rather  a palliative  than  a curative  means,  is  recommended 
by  Theden,  Ledran,  Monro,  Richard  Brown,  Chester,  Camper, 
Howship,  S.  Cooper,  and  several  other  surgeons ; it  is  regarded,  on 
the' contrary,  as  being  more  injurious  than  useful,  and  as  hastening, 
sometimes,  the  death  of  the  patient,  by  Callisen,  Denman,  Garengeot, 
Burns,  G.  Hunter,  Richter,  Sabatier,  Delpech,  etc.;  some  of  these 
writers,  though  they  do  not  positively  forbid  tapping,  think  with  good 
reason,  that  it  ought  not  to  be  resorted  to  except  as  an  extreme 
measure,  and  when  the  life  of  the  patient,  exposed  to  constant  danger, 
has  become  insupportable  in  consequence  of  the  inconveniences  and 
sufferings  which  result  from  the  enormous  distension  of  the  ovarian 
cyst. 

This  operation,  of  which  Ledran,  Monro,  Dehaen,  Portal  and  Dr. 
Hey,  have  published  cases  that  have  either  terminated  successfully 
or  prolonged,  for  a long  period,*  the  lives  of  the  patients,  has,  most 
generally,  been  followed  by  rapidly  fatal  accidents,  — a statement 
supported  by  the  cases  reported  by  Johnson,  Cleghorn,  Denman, 
Scudamore,  Ford,  Lizars,  Dupuytren,  Delpech,  Seymour,  Madame 
Boivin,and  several  other  practitioners  whom  it  would  be  useless  to  cite. 

Though  tapping  is  sometimes  successful,  or,  at  least,  renders  life 
more  bearable,  it  ought  never  to  be  decided  upon  hastily ; whether 
because  the  uterus  or  intestines,  etc.,  may  be  wounded,  examples  of 
which  we  could  cite  ; because  it  may  determine  rapidly  fatal  inflam- 
mations and  hemorrhages ; or,  because  it  may  occasion  a debility 
which  increases  so  rapidly  as  to  carry  off  the  patient  in  a few  days  ; 
or,  finally,  for  the  reason  that  it  fails  in  lessening  the  size  of  the  abdo- 
men when  the  dropsy  is  formed  of  several  small  cysts,  or  when  the 
substance  of  the  tumour  is  gelatinous  and  too  consistent  to  escape 
externally.  There  is  still  another  reason  which  ought  to  deter  prac- 

* In  a case  of  dropsy,  supposed  by  J.  Latham  to  be  seated  in  the  ovary,  tapping 
was  performed  one  hundred  and  fifty-five  times,  and  five  thousand  seven  hundred 
and  twenty  pints  of  fluid  evacuated,  and,  in  this  way,  the  life  of  the  woman  was  pro- 
longed for  several  years.  (Philosoph.  Transact.,  vol.  lxix.  part  i.  p.  54,  1779.)  In  the 
same  collection,  vol.  lxxiv.  part  ii.  p.  471,  year  1784,  is  the  history  of  a case  of  dropsy 
of  the  ovarium,  communicated  by  Ph.  Meadon,  Martineau  and  John  Hunter,  which  is 
remarkable  for  the  number  of  times  that  tapping  was  performed,  and  especially  for 
the  quantity  of  fluid  evacuated.  The  patient  underwent  eighty  operations,  in  the 
space  of  twenty-six  years,  and  furnished  six  thousand  six  hundred  and  thirty-one 
pints  of  fluid.  In  the  second  volume  of  the  Medical  Communications,  it  may  be  seen 
that  Ford  tapped  the  ovary  forty-one  times,  at  very  close  intervals,  because  the  col- 
lection formed  with  constantly  increasing  rapidity.  These  operations  furnished  two 
thousand  six  hundred  and  eighty-six  pints  of  serous  fluid. 


430 


DROPSY  OF  THE  OVARIUM. 


titioners  from  performing  paracentesis  of  the  ovarium,  except  in  the 
last  extremity ; which  is,  that  the  good  which  results  from  it  is  almost 
alwa5^s  ephemeral,  and  that  the  collection  reappears  after  each  opera- 
tion, with  a constantly  increasing  rapidity. 

When  compelled  to  resort  to  tapping,  it  should  be  performed  in 
the  following  manner : first,  after  arranging  the  woman  so  that  the 
tumour  becomes  as  salient  as  possible,  we  must  search  for  the  point 
where  fluctuation  is  most  marked,  and  where  the  cyst  seems  to  be 
thinnest,  and  then  the  trocar  must  be  introduced  obliquely  towards 
the  side  in  which  is  the  diseased  ovary,  so  as  to  avoid  wounding  the 
uterus. 

For  the  purpose  of  obtaining  a radical  cure,  by  inducing  sudden 
inflammation  of  the  cyst,  as  for  the  cure  of  hydrocele,  injections  have 
been  recommended;  but  this  method  was  not  followed  by  the  success 
looked  for.  Scudamore’s  patient,  referred  to  by  Lizars,*  treated  by 
port-wine  injections,  died  some  weeks  after  the  operation.  M.  Rams- 
den,t  surgeon  to  St.  Bartholomew’s  Hospital  in  London,  who  had 
injected  the  same  kind  of  wine,  mixed  with  water,  in  two  similar 
cases,  saw  his  two  patients  perish  from  the  effects  of  the  inflamma- 
tion ; the  woman,  mentioned  by  Denman,  died  at  the  end  of  six  days; 
lastly,  vinous  injections,  employed  on  a single  occasion,  under  the 
same  circumstances,  by  Dr.  Martini, £ of  Lubeck,  were  not  followed 
by  any  appreciable  result. 

With  a view  slowly  and  gradually  to  inflame  the  parietes ‘of  the 
cyst,  reduced  to  a small  volume,  it  has  been  attempted  to  convert  the 
wound  into  a fistula,  by  means  of  a sound  or  tent  retained  perma- 
nently in  place.  This  method  succeeded  with  Dehaen,  [Ratio  Me- 
dendi , t.  ii.  p.  255,)  in  a case  in  which  the  state  of  gestation  and 
the  more  or  less  considerable  size  of  the  womb,  kept  the  pouch, 
which  had  been  emptied  by  the  tapping,  constantly  compressed. 
Portal  also  relates  a successful  case,  treated  by  the  same  method ; 
lastly,  M.  Seymour  [toe.  cit.,  p.  103)  says  that  of  three  patients 
treated  in  this  way  by  Dr.  Key,  only  one  recovered,  while  the  other 
two  died,  soon  after,  of  acute  inflammation  and  profuse  suppuration. 

When  often  repeated  tappings,  or  the  permanent  retention  of 
a catheter  in  the  wound,  give  reason  to  fear  the  development  of  too 
acute  an  inflammation,  and  also  when  the  tumour  contains  matter 
of  a gelatinous  consistence,  Ledran§  proposed  treating  the  disease  by 
incision,  in  the  way  Delaporte||  practised  it.  The  latter  surgeon,  by 
means  of  an  incision  four  or  five  inches  in  length,  succeeded  in  ex- 
tracting, from  an  ovarian  tumour,  sixty-seven  pounds  weight  of  a 
thick  and  gelatiniform  matter ; the  patient  dying  thirteen  days  after, 
other  cysts  were  found  filled  with  the  same  substance,  a portion  of 
which  had  escaped  into  the  abdomen  through  certain  ulcerations  in 
the  principal  cyst.  The  two  cases,  given  by  Ledran.are  such  as  to  give 

* Edinburgh  Medical  and  Surgical  Journal,  No.  81. 

f Cooper’s  Surgical  Dictionary,  vol.  ii.  p.  255. 

* Journal  Hebdom.  de  M£d.,  t.  ii.  1829. 

§ Memoires  de  l’Acad.  de  Chirurgie,  t.  xi.  pp.  421  and  442. 

| Idem.  (loc.  citato,)  p.452. 


DROPSY  OF  THE  OVARIUM. 


431 


greater  encouragement  to  such  attempts ; for,  in  one  of  the  pa- 
tients operated  upon,  the  wound  remained  fistulous,  and,  in  spite  of 
a second  incision,  rendered  necessary  by  an  abscess  in  the  hypogas- 
triurn  and  a scirrhous  affection  of  the  ovary  which  daily  augmented 
in  size  and  complicated  the  dropsy  of  the  organ,  death  was  deferred 
for  several  years,  during  which  time  the  patient  enjoyed  tolerable 
health.  In  the  second  patient,  operated  upon  by  the  same  surgeon, 
the  cure  was  radical,  although  a number  of  accidents  occurred; 
among  others,  a suppuration,  at  first  abundant  and  fetid,  but  which, 
after  diminishing,  continued  to  discharge,  through  a fistulous  open- 
ing, for  two  years.  Notwithstanding  the  cases  just  mentioned,  and 
the  complete  success  obtained  in  some  similar  to  that  of  Delaporte, 
by  Dr.  Houston,  quoted  by  Monro,  (loc.  cit.,  p.  225,)  and  by  Portal, 
Denman,  and  MM.  Hay  and  Ramsden,  we  agree  with  Richter,* 
that  the  laying  open  of  the  cyst  of  the  ovary  generally  hastens  the 
death  of  the  patient  by  the  induction  of  very  extensive  inflammation, 
and  that,  where  the  consequences  are  not  immediately  fatal,  almost 
all  the  patients  perish,  before  long,  from  subacute  peritonitis  or  hectic 
fever. 

As  neither  single  nor  multiple  tapping,  nor  incision,  promises  ad- 
vantage, when  ovarian  dropsy  is  complicated  with  scirrhous  degene- 
ration, or  when  the  tumour  is  multi-locular,  and  divided  into  a larger 
or  smaller  number  of  cysts,  several  practitioners,  among  others  Felix 
Plater,!  Diemerbroeck,f  Power  and  Darwin, §,  Vanderhaar,  quoted 
by  Logger,  {de  ovariorum  morbis,  p.  76,)  Delaporte  and  Morand, 
[loc.  cit..,)  Siebold,  Lizars,  {loc.  cit.,)  etc.,  have  recommended  the 
extirpation  of  the  whole  of  the  diseased  organ,  as  is  done  almost  with 
impunity  in  the  females  of  various  animals,  for  the  purpose  of  render- 
ing them  sterile. 

Notwithstanding  these  cases,  and  although  the  loss  of  both  or  a 
single  ovary  has  happened  in  women,  without  fatal  results,  either 
after  operations  performed  for  ends  not  medical, ||  or  after  a wound, 
instances  of  which  are  cited  by  Franck  of  Francknau,  Poot,  by  Las- 
sus and  by  M.  Deneux,  the  methodical  extirpation  has  been  rejected, 
in  all  cases,  by  Dehaen,  {loc.  cit.,  t.  ii.  p.  88,)  by  Morgagni,  {epist.  38,) 
by  Sabatier,  by  Gardien,  by  M.  Murat  and  several  other  distinguished 
surgeons.  This  method,  which,  in  the  opinion  of  the  writers,  ought 
to  be  erased  from  the  list  of  useful  operations,  is,  to  a certain  degree, 

* Anfrangs  gruende  der  Wundarzneykunst,  th.  v.  p.  128. 

-j-  De  Mulier.  part,  generat.  dicatis.,  1597. 

\ Anat.  corporis  huraani,  1679. 

§ Zoonomia. 

|]  Isbrand  de  Diemerbroeck,  (Opera  omnia  anat.  loc.  cit.,)  relates  that  Adrometes, 
according  to  Athenseus,  and  Gyges,  King  of  Lydia,  according  to  Suidas,  often  caused 
the  ovaries  to  be  extirpated  in  women  of  their  kingdoms,  for  the  purpose  of  making 
them  barren.  According  to  some  authors,  this  custom, as  barbarous  as  it  is  immoral, 
prevailed  among  the  Egyptians  and  some  other  of  the  eastern  nations  also. 

Jean  Wier,  who  died  in  1588,  says  (Med.  obs.  rarior)  that  a sow-gelder,  suspecting 
the  virtue  of  his  daughter,  opened  her  abdomen,  drew  out  the  uterus,  and  cut  off  the 
ovaries.  The  author  adds  that  this  cruel  operation  was  followed  by  complete 
success. 


432 


DROPSY  OF  THE  OVARIUM. 


justified  by  several  cases  of  cure,  obtained  by  Lemaunier,*  by  Pa- 
roisse,  and  by  Dr.  Smith, t as  well  as  by  thp  three  cases  of  Dr.  Mac- 
do  well,  related  by  Lizars,  ( loc . cit.,)  by  the  extirpation  of  the  ovarium, 
successfully  performed  by  the  last-named  surgeon,  and  another  time 
by  Dr.  Chrysmer,  [Archives  de  Med.,  t.  xx.)  Finally,  it  is  justified, 
in  part  at  least,  by  the  cases  communicated  by  Delaporte,  Lieutaud 
and  Kapser,  and  by  the  more  or  less  successful  attempts  of  Lemman, 
Delpech,  Nathan,  MM.  Lafflize,  of  Nantes,  Ischier,  Dzondi,  Halles, 
and  of  some  others. 

We  ought  to  state,  moreover,  that  though  the  operation  has  some- 
times been  crowned  with  success,  it  has  more  frequently  been  fol- 
lowed by  unfavourable  results.  One  of  the  four  women  operated 
upon  by  Lizars,  survived  only  fifty-four  hours.  A patient  of  Dr. 
Martini’s  ( Arch.de  Med.,X.  xx.,)  and  two  others,  operated  upon  by  Dr. 
Chrysmer,  also  died  a few  hours  afterwards.  We  will  add,  moreover, 
that  the  operation  has  had  to  be  abandoned,  in  different  cases,  after 
the  incision  of  the  abdominal  parietes,  by  a surgeon  of  whom  Sir  A. 
Cooperi  speaks,  as  well  as  by  MM.  Lizars,  Grenville,  (/oc.  cit.,)  Dief- 
fenbach,  (Arch,  de  Med.,  t.  xx.,)  and  by  Galenzowski,  of  Wilna. 
WThen  the  cyst  was  exposed  to  view,  these  able  practitioners  deemed 
it  imprudent  to  extirpate  it,  either  because  of  numerous  adhesions 
that  had  been  formed,  or  because  of  the  great  number  of  large  ves- 
sels which  it  would  have  been  necessary  to  divide. 

Wre  conclude,  from  the  cases  that  we  have  just  related,  that  the 
extirpation  of  the  dropsical  ovarium  is  an  operation  which  may 
present  great  difficulty  and  always  the  greatest  dangers.  Without 
wishing  to  proscribe  it  entirely,  we  are  of  opinion  that  it  ought  not 
to  be  resorted  to  except  as  an  extreme  resource,  and  only  where  the 
mobility  of  the  tumour  gives  a certainty,  in  some  sort,  that  it  has  not 
contracted  adhesions,  or  that  they  are  at  least  of  small  extent.  A 
very  large  cyst,  the  least  uncertainty  in  the  diagnosis, § a complication 
with  ascites  and  different  indurations,  are  circumstances  which  con- 
tra-indicate the  operation.  We  will  add,  that  it  ought  not  to  be 
attempted,  even  under  the  most  favourable  circumstances,  unless  the 
patient  earnestly  desire  it. 

If  we  determine  that  the  operation  offers  the  only  chance  of  safety, 
the  tumour  ought  to  be  exposed,  by  an  incision  in  the  most  suitable 
point  of  the  abdomen,  by  an  incision  parallel  to  the  axis  of  the  body, 
and  of  as  small  extent  as  possible ; that  is  to  say,  from  three  to  five 
or  six  inches ; then,  if  the  cyst  were  adherent,  it  would  be  necessary 
to  endeavour,  after  the  example  of  Dr.  N.  Smith,  to  empty  it  with 
the  trocar,  and  afterwards  remove  it,  taking  care  to  destroy  the 
adhesions,  either  with  the  fingers  and  handle  of  the  scalpel,  or  by  a 

* Mem.  de  la  Societe  Royale  de  Med.,  1782,  p.296. 

t Edinb.  Med.  and  Surg.  Journal,  No.  72,  1822. 

* Diet,  of  Pract.  Surgery,  by  S.  Cooper,  vol.  xi.  p.  256. 

§ The  diagnosis  is  sometimes  so  uncertain  that  M.  Lizars  (Edinb.  Med.  Journal, 
No.  81)  acknowledges,  with  a candour  above  all  praise,  that  he  mistook  a swelling  of 
the  abdomen,  resulting  from  obesity,  for  a dropsy  of  the  ovary,  and  that  he  did  not 
perceive  his  mistake  until  after  he  had  made  an  extensive  incision  in  the  abdominal 
parietes. 


DROPSY  OF  THE  OVARIUM  AND  TUBES. 


433 


careful  dissection,  should  these  means  prove  insufficient.  Either 
ligature  or  torsion  of  the  vessels  ought  likewise  to  be  performed,  as 
they  are  divided.  Should  the  cyst  be  free,  movable  and  isolated, 
and  have  a narrow  pedicle,  it  is  sufficient  to  tie  its  root  firmly  and 
divide  it  beyond  the  ligature,  with  a bistoury,  or  with  long  scissors, 
curved  on  their  flat  surfaces.  In  case  the  tumour  were  fungous,  and 
had  a large  base,  with  numerous  vessels  of  a large  size,  it  would  be 
better  not  to  touch  it,  but  to  close  the  wound,  as  was  done  by  MM. 
Lizars,  Grenville  and  Dieffenbach.  It  is  well  to  add,  that  the  edges 
of  the  wound,  ought  to  be  held  together  by  adhesive  strips  or  with 
the  suture,  when  the  division  is  very  extensive. 

We  shall  conclude  by  saying,  that  since  ovarian  tumours  are 
rarely  composed  of  a single  cyst,  since  they  are  often,  on  the  contrary, 
multilobed,  and  adherent  at  several  points  ; as  they  contain,  in  the 
greater  number  of  cases,  something  more  than  serosity,  and  as,  more- 
over, the  dropsy, which  almost  always  ends  with  attacking  both  ovaries, 
is  not  unfrequently  complicated  with  other  lesions  which  render  the 
diagnosis  more  obscure  and  the  prognosis  more  unfavourable,  we  are 
tempted  to  say,  with  the  celebrated  Hunter,  ( Medical  Observ.  and 
Inquiries,  vo\.  ii.,)  that  the  patients  would  often  be  more  jikely  to 
prolong  their  existence,  if  no  attempt  were  made  to  deliver  them  of 
their  disease. 

Dropsy  of  the  Fallopian  tubes,  being  dependent  upon  the  same 
causes  and  presenting  the  same  symptoms  as  that  of  the  ovaries,  with 
which  it  is  almost  always  complicated,  and  from  which  it  cannot  be 
distinguished  until  after  death,  we  shall  be  content  with  saying  that 
medical  treatment  is  the  same,  and  that,  though  tapping  has  seemed, 
in  some  cases,  to  palliate  the  disease  and  prolong  the  lives  of  the 
patients,  it  has  generally  been  very  soon  followed  by  death.  We 
remark,  that,  the  matter  they  contain  is  often  thick  and  gelatinous, 
and  that,  like  the  ovaries  and  uterus,  they  are  sometimes  distended 
by  hydatids,  and  majr acquire  an  enormous  size.  Dehaen  ( loc . cit., 
U iii.  p.  29)  speaks  of  an  enlarged  Fallopian  tube,  which  weighed 
seven  pounds,  and  contained  twenty-three  pounds  of  fluid.  Frank 
(de  cur.  ret.,  lib.  vi.  p.  130)  saw  one  which  contained  thirty-two 
pounds  of  serous  and  gelatinous  matter.  Finally,  Blancard  ( anat . 
prat,  rat.)  met  with  a tube  distended  by  one  hundred  and  twelve 
pounds  of  serosity.  It  is  true,  that  the  ovary  and  broad  ligament 
likewise  formed  part  of  the  same  cyst.  In  women  who  die  of  this 
disease,  the  tubes  are  tortuous,  thickened,  elongated,  having  the 
appearance  of  the  large  intestines,  and  being  larger  in  proportion 
as  they  approximate  to  the  ovary.  Sometimes  they  enlarge  sud- 
denly, and  are  pyriform  or  spheroidal  in  shape. 

OF  CANCER  OF  THE  OVARIUM  AND  OTHER  DEGENERATIONS  OF 
THAT  ORGAN. 

The  ovarium,  like  the  uterus,  may  exhibit  various  morbid  growths 
and  degenerations,  upon  which  we  shall  say  but  a few  words,  be- 
cause any  circumstantial  details  that  we  might  give,  would  be,  in 
28 


434 


CAKCER  OF  THE  OVARIUM,  ETC. 


some  sort,  a mere  repetition  of  what  we  have  said  in  the  preceding 
chapters. 

Amongst  the  transformations  of  the  ovaries  ought  to  be  ranked  the 
fibrous  transformation , which  bears  so  strong  an  analogy  to  that  of 
the  uterus  that  it  is  often  impossible  to  determine  the  true  seat  of  the 
tumour,  not  only  during  the  life  of  the  patient,  but  even  with  the 
anatomical  specimens  before  the  eyes.  These  fibrous  productions, 
which  not  unfrequently  co-exist  With  those  of  the  uterus,  and  which, 
like  those  of  that  viscus,  may  be  developed  either  at  the  surface,  or 
within  the  proper  tissue  of  the  organ,  vary  prodigiously  in  size  and 
weight,  since  they  have  been  known  to  weigh  from  a drachm  to  more 
than  forty  pounds.  M.  Cruveilhier*  lately  found,  in  a woman  who 
died  at  the  Salpetriere  Hospital,  a tumour  of  the  ovary,  weighing 
forty-six  pounds.  We  ought  to  state,  also,  that  this  organ  may,  like 
the  uterus,  become  the  seat  of  cartilaginous,!  osseous.!  petrous, § 
tubercular|]  and  melanic^  transformations,  which  can  be  recognized 
only  by  autopsical  examination. 

Of  all  the  degenerations  of  the  ovary,  the  cancerous  is,  beyond  all 
contradiction,  the  most  important  to  study,  because  of  the  frequency 
of  its  unfortunate  results,  and  of  the  terrible  pain  it  almost  always 
occasions.  Cancer  of  the  ovary  may,  like  that  of  the  womb,  present 
itself  in  every  form,  which  are  often  combined  together  or  with  other 
alterations.  Nevertheless,  scirrhous  and  encephaloid  cancer,  which 
are  always  rather  hard  to  distinguish  from  each  other  even  after 
death,  have  been  more  frequently  observed  than  the  other  varieties 
that  we  pointed  out  while  treating  of  this  disease  when  situated  in  the 
uterus. 

Cancerous  ovaria  sometimes  attain  a very  large  size,  and,  in  that 
case,  alter  all  the  relations  of  the  surrounding  parts  to  each  other. 
Morgagni  speaks  of  a cancerous  ovary  which  weighed  twenty-four 
pounds.  M.  Velter  saw  one  weighing  fifty-six  pounds,  and  M.  Caillot 
another  of  the  same  weight. 

The  causes  of  cancer  of  the  ovary  are  but  little  known ; every 
thing,  however,  tends  to  make  us  suppose  that  the  degeneration  has 
the  same  origin  as  chronic  ovaritis,  of  which  it  is  often  the  termi- 
nation. All  that  we  can  say  positively  is,  that  cancer  of  the  ovary 
is  met  with  at  least  as  frequently  as  that  of  the  breasts,  and  that  it 
yields  in  frequency  only  to  that  of  the  uterus,  with  which  it  coin- 
cides sometimes  consecutively. 

The  symptoms  of  the  disease  are  very  obscure  in  the  early  stage 
of  its  existence ; later,  when  the  increase  of  the  tumour  might  lead 
to  the  suspicion  of  a cancer  of  the  ovary,  it  is  difficult  to  distinguish 

* Dictionnaire  de  m^decine  et  de  chirurg.  prat.,  t.  xii.  p.  414. 

t Kluisken,  Annales  de  litter,  etrang.,  t.  ix.  p.  336.  Dupuytren,  Bulletin  de  la  Fa- 
culte  de  Med.,  No.  3,  1806.  Caillot,  Acad^mie  de  Med.,  Jan.  13th,  1824.  Velter,  idem, 
July  12,  1825. 

* Logger,  De  ovarior.  morb.,  p.  12.  Seymour,  loc.  cit.,  p.  56. 

§ Haller,  Disput.  ad  morb.,  t.  iv.  p.  420,  (d’apres,  Schleuker.)  Saviard,  Nouv.  reeueil 
d’ob.serv.,  1702. 

I|  Seymour,  loc.  cit.  Tonnele,  Journal  bebdom.  de  m£d.,  t.  v.  1829. 

1 Morgagni,  de  sedibus  et  caus.  morb.  epist.,  21,  22,  31,  39. 


CANCER  OF  THE  OVARIUM,  ETC. 


435 


it  from  the  other  vital  lesions  Of  which  we  have  just  spoken  ; in 
proportion  as  the  disease  advances,  the  pain,  which  i$  felt  in  one  of 
the  sides  of  the  pelvis,  and  which  was  dull  and  not  continued  at 
first,  becomes  more  acute,  and  assumes  more  and  more  the  character 
of  that  belonging  to  the  cancerous  degeneration. 

When  the  disease  appears  in  the  scirrhous  form,  the  tumour  grows 
slowly,  and  it  has  sometimes  been  known  to  augment  insensibly  for 
ten  and  even  thirty  years,  without  giving  rise  to  any  marked  de- 
rangement of  the  functions,  or  to  very  acute  pain;  often,  the  only 
inconveniences  which  the  patient  experiences  are  sensation  of  unea- 
siness, proportioned  to  the  weight  and  development  of  the  scirrhus, 
and  some  disorders  of  the  menstruation,  which,  moreover,  are  far 
from  being  always  present.  Encephaloid  cancer,  on  the  contrary, 
grows  with  rapidity,  may  become  enormous  in  a few  months,  and 
cause  the  lancinating  pains  characteristic  of  the  degeneration.  When 
the  disease  approaches  a fatal  termination,  the  tumour,  which  be- 
comes irregular,  and  more  and  more  enlarged,  softens  in  certain 
points;  the  shooting  pain,  which  has  been  compared  to  the  pricking 
of  needles,  becomes  more  and  more  severe,  and  extends  to  the  neigh- 
bouring parts,  to  the  uterus,  vulva,  loins  and  thigh  corresponding 
to  the  diseased  side ; haemorrhages,  discharges  of  an  ichorous  cha- 
racter and  disgusting  odour,  escape  from  the  vagina,  which,  by  exten- 
sion of  the  degeneration,  often  produces  fungous  vegetations,  of 
a granulated  and  livid  reddish  appearance.  The  pains  extend  sym- 
pathetically to  the  knees,  the  legs,  the  breast  and  the  shoulders  ; the 
stomach,  particularly,  is  affected;  the  digestion  is  imperfectly  per- 
formed ; the  patient,  who  acquires  an  extreme  disgust  for  food,  is 
also  troubled  with  nausea  and  vomiting,  together  with  obstinate  con- 
stipation of  the  bowels ; lastly,  a state  of  insomnia,  amounting  to 
almost  absolute  sleeplessness,  a permanent  condition  of  hystericism, 
rapid  emaciation,  and  continual  fever,  are  harbingers  of  her  approach- 
ing end,  the  inevitable  result  of  this  scene  of  pain. 

The  diagnosis  of  cancer  of  the  ovary,  while  in  the  state  of  scirrhus 
properly  so  called,  is  always  difficult,  especially  in  the  early  stages  of 
the  attack  ; but  where  the  disorder  is  more  acute,  the  hardness  of  the 
tumour,  the  absence  of  any  fluctuation,  and  lastly,  the  lancinating 
pains,  sufficiently  distinguish  it  from  encysted  dropsy,  from  fibrous 
tumour  of  the  uterus,  and  from  extra-uterine  pregnancy ; we  may 
also  avoid  confounding  the  symptoms  with  those  of  great  masses  of 
faeces  accumulated  in  the  caecum,  or  colon,  by  remembering  that  tu- 
mours produced  by  the  causes  last  mentioned  appear  and  disappear, 
and  change  their  situation,  according  to  the  posture  of  the  patient ; 
besides,  the  Touch  per  vaginam,  and  the  origin  and  antecedents  of  the 
disorder  largely  contribute  to  the  dissipation  of  every  doubt. 

The  prognosis , although  always  serious,  differs  according  to  the 
form  of  the  cancer,  the  volume  of  the  tumour,  and  the  complications 
of  the  disease.  Encephaloid  degeneration  is  the  most  serious  of  all, 
and  the  one  whose  termination  is  most  speedily  fatal.  But,  with 
regard  to  the  ovary,  we  make  the  same  remarks  as  with  regard  to 
the  uterus  ; that  is  to  say,  according  to  the  order  of  gravity  in  these 


436 


CANCER  OF  THE  OVARIUM,  ETC. 


varieties,  the  first  to  be  named  is  the  encephaloid  cancer,  the  one 
most  frequently  met  with  in  dissection,  next  the  haematode  or  blood- 
cancer,  which  has  been  thrice  noticed  by  Hooper,*  the  fungous 
cancer,  of  which  Professor  Proschaska  has  given  a description,  ac- 
companied by  a drawing,  {Disc,  or g arris  mi  corpor.  human .,  plate  v,) 
and  lastly,  the  scirrho-cancer,  which  is  the  first  stage  of  the  other 
kinds,  and  the  least  unfavourable  as  regards  its  diagnosis,  for  we 
may  often  succeed  in  arresting  its  growth.  We  may  add,  that  it 
frequently  co-exists  with  encysted  dropsy  of  the  ovarium,  with  which  . 
it  makes  a distressing  complication,  or  of  which  it  may  be  either  the 
effect  or  the  cause. 

The  treatment  of  the  degeneration  under  consideration,  ought  to 
be  merely  palliative ; for,  in  spite  of  the  pretended  cures  published 
by  certain  authors,  the  disease  is  beyond  the  resources  of  medical 
therapeutics.  Small  venesections,  prolonged  bathing,  narcotics,  de- 
mulcent and  cooling  drinks,  emollient  and  anodyne  enemata,  gentle 
laxatives,  a mild  regimen,  principally  vegetable, — such  are  the 
measures,  by  the  prescription  of  which  we  may  succeed  in  mo- 
derating the  violence  of  the  symptoms,  and  retarding  the  progress 
of  the  malady.  Where  the  menses  are  suppressed,  which  is  often 
the  case,  we  should  endeavour  to  recall  them,  or  supply  the  want 
of  them  by  applying  leeches  to  the  vulva  or  anus,  in  small  num- 
bers at  each  time  ; or  we  might  equally  well  establish  issues,  and  give 
orders  for  douches  of  sulphurous  or  alkaline  solutions ; mercurial 
frictions  made  upon  the  tumour,  and  the  internal  use  of  cicuta,  and 
the  other  so-called  anti-scirrhous  articles  mentioned  in  our  remarks 
upon  cancer  of  the  womb,  should  be  turn  by  turn  attempted,  with  a 
view  not  to  cure,  but  to  console  the  patient.  Where  the  scirrhous 
tumour  has  become  softened,  and  taken  on  the  encephaloid  character, 
or  any  other  of  the  cancerous  transformations,  the  treatment,  which 
ought  to  be  varied  according  to  the  nature  of  the  symptoms,  should 
consist  of  cares  accessary  and  subordinate  to  the  precise  kind  of 
inconvenience  suffered  by  the  sick  person.  We  further  add,  that, 
in  this  disease,  as  well  as  in  dropsy  of  the  ovarium,  the  extirpa- 
tion of  the  organ  has  been  proposed,  and  which,  as  we  have  seen  in 
the  preceding  chapter,  has  been  sometimes  crowned  with  success. 
We  think,  however,  that  the  results,  as  yet  obtained,  are  not  sufficient 
always  to  justify  so  grave  an  operation,  and  that  too  much  blame  could 
not  be  cast  upon  any  attempt  of  the  kind  in  a patient  exhibiting  the 
signs  of  the  cancerous  diathesis,  a degeneration  of  the  same  sort  affect- 
ting  any  other  organ,  or,  in  fine,  an  hereditary  disposition  to  cancer. 

Although  the  Fallopian  tubes  are  subject  to  the  same  diseases  as 
the  ovaries,  we  shall  not  treat  of  them  here,  as  any  details  we  might 
give  would  be  of  no  avail  in  enlightening  the  practitioner  as  to  the 
treatment,  and  would  be  interesting  only  in  a treatise  on  pathological 
anatomy,  for  the  different  lesions  of  the  tubes  can  only  be  determined 
upon  the  dead  and  not  upon  the  living  body,  and  since,  also,  they 
almost  always  coincide  with  the  diseases  of  the  ovarium. 


The  Morb.  Anat.  of  the  human  uterus,  pi.  xxi. 


CANCER  OF  THE  VAGINA  AND  EXTERNAL  GENITALS. 


437 


CANCER  OF  THE  VAGINA  AND  EXTERNAL  ORGANS  OF  GENERATION. 

Cancer  of  the  vagina  may  be  either  a primary  disorder,  or  a mere 
extension  of  cancer  uteri,  or  of  the  same  malady,  situated  in  the 
external  genitals.  When  primary,  it  may  arise  from  the  simple 
degeneration  of'  an  eroded  point,  a simple  or  syphilitic  ulcer,  a ne- 
glected or  ill-treated  cancerous  excrescence,  or  from  ulceration  of  a 
scirrhous  induration  situated  in  the  lining  membrane,  or  in  the  proper 
texture  of  the  vaginal  parietes.  Primary  cancer  of  the  vagina  is  a 
somewhat  less  serious  affection  than  cancer  of  the  womb,  especially 
when  it  is  situated  near  the  orifice  of  the  vulva.  A cancer,  conse- 
cutive of  one  of  the  womb,  is  far  more  serious,  for  it  is  a complication 
and  an  extension  of  the  primary  malady,  whose  fatal  result  is  greatly 
accelerated  by  it. 

Cancer  of  the  clitoris  generally  commences  like  cancer  of  the 
penis  at  the  glans.  Whatever  be  the  form  under  which  it  attacks,  it 
may  depend  upon  an  irritation  proceeding  from  syphilitic  ulcers, 
from  solitary  erotic  excesses,  from  frequent  and  prolonged  frictions 
and  excitation.  Under  the  influence  of  one  or  more  of  these  causes, 
the  clitoris  has  been  found  to  grow  to  the  size  of  the  thumb,  and 
sometimes  to  give  risq  to  a pediculated  fungous  tumour  of  the  size  of 
the  fist,  presenting  a softish  mass  of  a whitish  livid  or  reddish  colour, 
covered  with  bunches  of  granulations  secreting  an  ichorous  fluid. 

Cancer  of  the  meatus  urinarius,  like  cancer  of  the  nymphse, 
almost  invariably  arises  from  degenerated  ulcerations,  whether  of  a 
simple  or  syphilitic  nature,  irritated  by  the  permanent  contact  of 
the  urine,  or  by  improper  dressings.  The  same  may  be  stated  as  to 
cancer  of  the  labia  pudendi,  whose  vascular  tissue  is  very  irritable,  and 
exhibits,  in  a high  degree,  a structure  favourable  to  the  development 
of  the  cancerous  ulceration.  The  vaginal  discharges  and  the  fric- 
tions from  walking,  or  frequent  coitus,  may  likewise  contribute  much 
to  the  production  of  cancer  of  the  labia,  and  the  other  organs  apper- 
taining to  the  vulva.  We  add,  that  the  carcinomatous  affections  of 
these  parts,  like  those  of  the  vagina,  may  also  be  the  disastrous 
consequences  of  the  gradual  spread  of  the  same  vice  from  a pri- 
mary development  of  it  in  the  womb.  It  is  well,  too,  to  remember, 
that  the  inverse  of  this  proposition  may  hold  good,  that  is,  that  the 
disease  may  extend  from  the  vulva  along  the  vagina,  and  thence 
to  the  womb  itself. 

As  there  is  generally  some  uncertainty  as  to  the  nature  of  the  dis- 
order, it  is  always  well  to  begin  the  treatment  by  the  use  of  mercu- 
rials, both  locally  and  internally  exhibited,  and  that  conjointly  with 
antiphlogistics,  and  especially  topical  bleeding,  and  emollient  and  nar- 
cotic fomentations.  Should  the  symptoms,  instead  of  ameliorating, 
become  exasperated,  it  might  be  deemed  necessary,  in  order  more 
certainly  to  arrest  the  progress  of  the  evil,  to  resort  to  certain  surgical 
operations  which  we  are  about  to  describe.  Where  the  disorder  is 
confined  to  the  vagina,  we  are  restrained  to  the  use  of  a mere  pal- 
liative treatment ; should  it,  however,  be  found  to  be  superficial,  and 
should  it  appear  possible  to  destroy  all  the  parts  affected,  recourse 
might  be  had  to  cauterizations,  with  the  liquid  acid-nitrate  of  mer- 


438  (EDEMA,  VARIX,  AND  OTHER  VULVAR  TUMOURS. 

curv,  or  even  with  the  arsenical  paste.  Should  the  mischief,  how- 
ever, not  extend  beyond  the  orifice  of  the  meatus  urinse,  the  whole 
of  that  point  might  be  removed  with  the  bistoury.  The  canal  of 
the  urethra,  be  it  observed,  cicatrizes  very  readily,  and  continues  to 
perform  its  functions,  even  where  it  has  been  curtailed  of  several 
lines  of  its  length.  The  operation  is  performed  with  a pair  of  pin- 
cers, and  a scissors  curved  Qn  the  flat,  which  serve  equally  well  for 
the  incision  of  the  clitoris  and  of  the  nymphae.  To  the  bleeding  that 
follows  these  several  operations,  the  usual  haemostatic  remedies 
are  directed,  but  especially  the  actual  cautery,  which  possesses  the 
additional  value  of  being  useful  for  the  utter  eradication  of  the  last 
vestiges  of  the  disease  ; should  the  disease  reappear,  it  should  be 
again  attacked  either  with  the  knife,  the  red-hot  iron,  the  nitrate  of 
silver,  or  the  liquid  acid-nitrate  of  mercury. 

The  treatment  of  cancer  of  the  labia  is  likewise  wholly  chirur- 
gical,  that  is  to  say,  it  consists  in  the  extirpation  of  the  parts  affected. 
The  operation  is  in  general  neither  tedious  nor  difficult,  and  when 
the  case  requires  it,  we  may  venture  to  remove  almost  the  whole  of 
the  external  genitals,  for  experience  has  proven  that  few  very  seri- 
ous inconveniences,  and  but  very  little  disturbance  of  the  functions, 
are  the  consequences  of  the  operation.  The  bigeynorrhage  ought  espe- 
cially to  attract  our  attention  ; for,  as  the  blood  oozes  from  almost 
every  part  of  the  wounded  surface,  we  are  often  obliged  to  arrest  it 
by  means  of  the  incandescent  iron.  In  cases  where  the  cautery 
might  not  appear  to  be  indispensable,  and  with  a view  to  obviate 
the  attack  of  a secondary  htemorrhage,  pressure  might  be  made  on 
the  bleeding  surfaces  with  small  balls  of  charpie  sprinkled  with  resin 
or  ashes,  and  covered  with  several  discs  of  agaric,  sustained  by 
compresses  and  a T bandage.  We  ought  to  observe,  that  previously 
to  commencing  the  dressing,  it  is  important  to  introduce  and  secure 
a catheter  in  the  bladder,  so  as  to  allow  a free  passage  to  the  urine, 
and  keep  the  dressings  from  becoming  soaked  with  it.  Care  should 
also  be  taken  to  plug  up  the  orifice  of  the  womb  with  charpie,  to 
hinder  any  blood  that  might  still  continue  to  flow,  from  getting 
within,  and  remaining  within  the  canal  of  the  vagina.  It  is  hardly 
requisite  to  remark,  that  for  the  performance  of  these  operations,  the 
woman  must  be  placed  in  the  same  manner  as  for  the  application  of 
the  speculum. 

OF  (EDEMA,  VARIX,  AND  OTHER  TUMOURS  OF  THE  VULVA. 

(Edema  of  the  labia  is  generally  the  extension  of  anasarca  pro- 
ceeding from  ascitic  dropsy,  or  from  the  state  of  pregnancy.  Some- 
times it  accompanies  a local  inflammation,  especially  an  erysipelas, 
but  it  then  becomes  a more  serious  matter  than  the  cedematous  en- 
gorgement from  the  other  causes  we  have  mentioned. 

(Edema  of  the  vulva  is  known  by  a certain  swelling  of  the  labia 
externa,  which  becomes  tense,  shilling,  of  a rose  colour,  transparent, 
very  little  sensitive  to  pressure,  and  retaining  the  impression  made 
by  the  fingers  when  pressed  upon  the  surface. 


(EDEMA,  VARIX,  ETC.,  OF  THE  VULVA. 


439 


This  oedematous  engorgement  of  the  labia  majora  looks  like  a 
thick  and  protuberant  cushion,  which  may  become  so  very  large  as  to 
interfere  with  the  act  of  walking,  become  an  obstacle  to  that  of  par- 
turition, and  also  prevent  the  proper  exercise  of  the  Touch  per  vagi- 
nam,  by  hindering  the  point  of  the  finger  from  penetrating  as  far  as 
the  os  tincse. 

The  surgical  treatment  of  oedema  of  the  labia  consists  in  a steady 
compression  of  the  parts ; but  when  the  swelling  is  very  great,  we 
should  attempt  to  discharge  the  fluid  by  means  of  small,  shallow 
punctures  made  with  the  point  of  a lancet.  An  inflammatory 
oedema  accompanied  with  fever,  demands  the  use  of  antiphlogistics, 
such  as  venesection,  the  application  of  leeches  to  the  inside  of  the 
thighs,  and  not  to  the  diseased  parts;  cooling  drinks,  emollient,  nar- 
cotic and  slightly  resolvent  applications ; and,  lastly,  dieting,  and  rest 
in  a horizontal  posture  ; such  are  the  remedies. 

Varices  of  the  labia  constitute  a rather  rare  affection,  which  differs 
from  all  other  tumours  of  the  vulva  by  the  following  characters:  the 
dilated  veins  form  beneath  the  skin  on  one  side,  and  the  mucous  mem- 
brane on  the  opposite  side  of  the  labium,  certain  nodosities  or  lumps, 
which  are  more  or  less  protuberant  as  they  are  of  an  older  or 
fresher  date.  The  tumours  are  indolent  upon  pressure,  of  a bluish 
colour,  and  a consistence  so  soft  that  they  disappear  under  pressure, 
to  reappear  again  as  soon  as  the  pressure  is  taken  off.  In  some 
cases  these  tumours  become  irritated,  and  then  they  inflame,  when 
they  become  the  seats  of  fungous  ulcers  difficult  to  heal.  It  should 
be  also  stated  that  what  renders  the  disorder  in  some  instances  quite 
distressing,  is  the  pruritus  of  the  sexual  parts  with  which  it  is  accom- 
panied. 

The  principal  causes  of  varix  are  too  frequent  coitus,  and  particu- 
larly the  violent  frictions  that  may  attend  it ; pregnancy,  too  often 
repeated ; laborious  labours,  and  the  repeated  and  prolonged  irrita- 
tions they  give  rise  to.  These  circumstances  are  especially  favoura- 
ble to  the  development  of  the  disease  in  females  in  whom  the  veins 
are  of  a large  size,  dilatable,  and  with  coats  that  have  but  little  resist- 
ing power. 

The  treatment  of  varix  of  the  vulva  is  very  simple;  the  disorder 
often  disappears  spontaneously  upon  the  cause  that  produced  it  ceas- 
ing to  act.  When  the  labia  are  indolent,  recourse  is  mostly  had,  and 
with  advantage,  to  cold  and  astringent  topical  remedies,  such  as  com- 
presses moistened  with  liquid  acetate  of  lead,  a decoction  of  tan,  or 
Provence  roses,  or  a weak  solution  of  sulphate  of  alumina  in  a mix- 
ture of  water  and  claret.  To  these  remedial  measures  should  be 
added  an  entire  abstinence  from  the  coitus,  and  a steadily  maintained 
compression  of  the  parts,  where  that  can  be  effected  without  too 
great  a degree  of  inconvenience.  Cases  of  painful  and  irritative  varix 
should  be  managed  by  means  of  rest,  opiated  cerates,  topical  bleed- 
ings, and,  lastly,  by  using  the  chloruret  of  the  oxide  of  sodium  as  a 
lotion  where  the  varicose  tumours  have  become  the  seats  of  ulcera- 
tion. 

Encysted  tumours  of  the  labia  are  of  sufficiently  frequent  occur- 


440 


(EDEMA,  VARIX,  ETC.  OF  THE  VULVA. 


rence,  and  are  easily  distinguishable  from  all  other  tumours  of  the 
labia  pudendi,  by  their  rounded  and  circumscribed  form ; they  occa- 
sion no  alteration  in  the  colour  of  the  skin;  their  consistence  is  some- 
what fluctuating,  and  their  substance,  which  is  neither  pasty  nor 
translucent,  nor  diffused,  as  in  oedema,  does  not  show  the  hardness 
and  the  resistance  of  the  fibrous  tumours  with  which  it  is  not  difficult 
to  confound  them.  Besides,  a mistake  in  the  diagnosis  is  of  no  very 
great  moment,  since  the  extirpation  of  the  tumour  is  equally  appli- 
cable to  both  cases. 

Encysted  tumours  of  the  vulva  exhibit  a resistance  to  the  touch 
that  differs,  according  to  the  nature  of  the  material  contained  within 
them ; though  the  cyst,  whose  parietes  are  smooth,  and  of  a whitish 
colour,  is  mostly  distended  with  a serous  fluid,  its  cavity  is  in  some 
specimens  found  to  be  filled  with  a thick  brown  liquid.  Cases  are 
seen  of  a spontaneous  opening  of  this  kind  of  tumour,  which  gives 
rise  to  an  inconvenient  and  constant  oozing,  which  rarely  dries  up 
without  the  assistance  of  art. 

The  treatment  of  encysted  tumours  of  the  labia  majora,  like  that 
of  the  fibrous  tumours,  consists,  as  we  have  already  said,  solely  in 
their  extirpation,  which  is  performed  as  follows : after  placing  the 
patient  in  a proper  posture,  we  seize  the  labium  and  turn  it  over 
outwards,  then  fixing  the  tumour  firmly  by  a finger  behind  it  so  as 
to  make  it  project  more,  a small  incision  should  be  made  on  the  inner 
surface,  whether  because  the  cyst  or  fibrous  tumour  is  nearer  to  the 
surface  at  that  point,  or  because  it  is  desirable  to  avoid  making  a 
disagreeable  scar.  When  the  tumour  is  fairly  uncovered,  the  sur- 
geon should  endeavour  to  detach  it  from  all  its  connections  by  a 
minute  dissection,  and  pressing  his  finger  behind  it  still  more  strongly 
so  as  to  make  it  project,  he  will  remove  it  as  completely  as  possible 
with  the  scissors.  Should  the  cyst  happen  to  be  laid  open  during 
the  operation,  it  is  proper  to  remove  every  part  of  it  that  can  be 
reached,  and  then  cauterize  the  whole  internal  surface  of  the  wound 
with  a view  to  prevent  the  reproduction  of  the  disease.  In  case  of 
profuse  haemorrhage,  it  might  be  treated  by  the  ligature,  but  above 
all,  by  the  incandescent  iron. 

The  mucous  surface  of  the  labia  may  also,  in  certain  cases,  become 
the  seat  of  small  pediculated  polypous  tumours,  distinguishable  by 
their  shape  from  the  vegetations  of  cancer  and  syphilis,  and  which 
are  treated  by  exscinding  them  with  scissors  curved  on  the  flat.  It  is, 
further,  not  very  rare  to  see  lipomatous  tumours  growing  in  the  sub- 
stance of  the  labia  ; they  offer  the  same  character  as  similar  tumours 
in  other  parts  of  the  body,  and  require  the  same  curative  means, 
that  is  to  say,  as  complete  a removal  and  destruction  as  possible. 
The  incision  also  suits  for  the  removal  of  certain  vegetations  or  par- 
tial hypertrophies  of  some  of  the  vulvar  tissues,  such  as  warts, 
small  cellular  tumours  filled  with  serosity,  the  venereal  poireaux , 
&c.  Let  it  be  added,  that,  when  these  tumours  attain  a certain  size, 
they  become,  though  not  painful  in  themselves,  very  inconvenient  to 
the  patient,  and  give  rise  to  constant  dragging  pains,  extending  as  far 
as  the  inguinal  and  lumbar  regions. 


CANCER  OF  THE  BREAST. 


441 


CANCER  OF  THE  BREAST. 

Cancer  of  the  breast,  from  being  very  common,  easily  observable, 
and  moreover  most  accessible  to  the  surgeon,  has  been  more  studied, 
and  has  excited  a more  especial  interest  than  the  same  malady  in 
any  of  the  other  organs  of  the  body.  This  affection,  beyond  contra- 
dictibn  the  most  serious  malady  to  which  the  breast  is  liable,  is  in- 
comparably more  frequent  in  the  female  than  in  the  male,  notwith- 
standing the  mammary  glands  are  originally  precisely  alike  in  both 
the  sexes.  It  is  easy  to  explain  this  happy  privilege,  and  this  differ- 
ence in  our  favour,  if  we  but  reflect  that  the  mammae  in  women 
have  a much  more  important  function  to  perform  than  in  men,  and 
are  more  exposed  to  the  contact  and  influence  of  external  causes, 
and  also  suffer  from  irritations  and  sympathetic  excitements  growing 
out  of  the  state  of  pregnancy,  the  mensual  periods,  and  ail  the  modi- 
fications, whether  normal  or  pathological,  of  the  functions  of  the 
reproductive  organs. 

This  most  serious  disorder  of  the  female  breast  seems  preferably 
to  develop  itself  in  the  marriage  state,  after  the  lactations,  in  those 
who  have  large  breasts,  and  chiefly  at  the  period  of  life  corresponding 
with  that  of  the  final  cessation  of  the  menses.  Cancer  of  the  breast 
has  been  seen,  however,  at  the  age  of  twenty  and  of  thirty,  but 
much  more  generally  betwixt  the  thirtieth  and  fortieth  year. 

The  occasional  causes  of  cancer  of  the  breast  are  either  internal 
or  external ; among  the  latter  are  classed  blows,  falls,  contusions, 
the  pressure  of  tight  corsets,  adjusted  with  a view  to  push  the  breasts 
upwards,  or,  on  the  other  hand,  to  flatten  them,  and  lessen  their  appa- 
rent size ; the  bad  habit  indulged  in  by  some  women,  of  not  sup- 
porting the  breasts,  but  abandoning  them  to  their  own  weight; 
the  inconsiderate  use  of  discutient  and  irritating  topicals  for  the 
breast  when  inflamed,  or  affected  with  simple  and  chronic  engorge- 
ments ; and  lastly,  the  sudden  impression  of  cold  air,  especially  soon 
after  a confinement,  and  the  astringent  applications  designed  to  check 
the  secretion  of  the  milk.  These  are  justly  regarded  as  capable  of 
acting  as  the  occasional  causes  of  scirrhous  indurations.  We  may 
add,  that  it  is  generally  agreed  that  chronic  inflammations  of  the 
breast,  its  milk  engorgement,  its  herpetic,  scrofulous,  syphilitic  and 
other  engorgements,  may,  in  some  instances,  degenerate  into  cancer. 

The  internal  causes  of  the  affection  under  consideration,  are,  irre- 
gularities and  accidental  suppression  of  the  menstruae ; the  cessation 
of  a long  chronic  leucorrhoea,  or  piles,  or  profuse  habitual  sweat;  the 
drying  up  of  an  old  issue,  the  repercussion  of  certain  exanthematous 
disorders,  of  psoric  and  herpetic  affections ; the  metastasis  of  gout, 
rheumatism,  wandering  erysipelas,  as  in  cases  of  the  kind  reported 
by  Pouteau ; and  a variety  of  other  causes  more  or  less  evident ; 
which,  like  those  now  above  mentioned,  are  incapable  of  giving  rise 
to  an  attack  of  cancer,  except  where  they  coincide  with  some  occult 
cause  whose  essence  is  unknown,  that  is  to  say,  a disposition  which 
is  interior,  and  individual  for  the  person  who  suffers,  and  which  is 
commonly  designated  by  the  term  cancerous  diathesis.  According 
to  some  practitioners,  this  mere  disposition  to  have  cancer  suffices, 


442 


CANCER  OF  THE  BREAST. 


in  some  instances,  to  give  birth  to  the  malady,  while  in  others  it  may 
co-exist  with  the  whole  duration  of  life,  without  exhibiting  itself  in 
any  external  symptoms.  It  has  further  been  supposed,  that  the  can- 
cerous diathesis  does  not  always  exist  in  the  same  degree  of  inten- 
sity, which  may  explain  why  a slight  irritation  may  be  enough  to 
provoke  the  development  of  cancer,  whereas,  in  other  circumstances, 
it  requires  the  concurrent  operation  of  many  powerful  occasional 
causes,  to  give  life  to  the  malady. 

Progress  arid  symptoms.  A cancerous-  degeneration  of  the  breast 
most  commonly  begins  as  a small  tumour,  more  or  less  regularly 
rounded,  hard,  circumscribed,  movable  under  the  finger,  indolent, 
without  change  in  the  colour  of  the  skin,  and  situated,  which  is  most 
common,  in  some  point  of  the  adipose  tissue  of  the  breast,  or  in  the 
body  of  the  mammary  gland  itself,  whose  parenchyma  becomes  hard, 
heavy,  compact,  and  more  or  less  voluminous  as  to  its  size. 

A scirrhous  tumour  that  has  formed  in  the  adipo-cellular  tissue  of 
the  breast,  may  be  readily  circumscribed  with  the  fingers,  for  it  is 
completely  isolated  by  the  cellular  layers  which  surround  it  like  the 
walls  of  a real  cyst.  In  the  rarer  cases,  where  the  morbid  indura- 
tion has  commenced  by  affecting  the  mammary  gland  itself,  the  ab- 
normal tumour  cannot  be  circumscribed,  and  runs  into  the  sound, 
parts  in  every  direction,  and  is  confounded  with  them.  Where  the 
whole  gland  is  invaded,  it  becomes  transformed  into  an  irregular 
botryoidal  mass  with  the  nipple  adhering  to  it,  and  enveloped  in  a 
certain  quantity  of  cellular  and  adipose  tela. 

During  the  early  stages  of  cancer  it  often  happens  not  only  that 
the  health  of  the  patient  undergoes  no  depravation,  but,  on  the  con- 
trary, it  appears  that  her  freshness  and  embonpoint  actually  improve. 
Unfortunately,  however,  after  the  lapse  of  a period  of  uncertain  dura- 
tion, the  progress  of  the  disease  comes  to  cheat  all  these  false  hopes. 
In  general,  after  having  received  some  blow — some  pressure,  after 
the  natural  or  morbid  suppression  of  the  menses,  or  even  without  any 
known  cause,  the  isolated  tumour  grows  rapidly,  spreads  in  every 
direction  among  the  neighbouring  parts,  with  which  it  forms  adhe- 
sions so  as  gradually  to  invade  the  whole  breast.  A scirrhus  that 
has  begun  by  the  mammary  gland  proper,  also,  under  such  circum- 
stances, takes  on  a new  power  of  extension,  that  is  to  say,  after  having 
involved  the  entire  gland,  it  seizes  upon  the  adipose  tissue  round 
about  it,  and  continuing  its  progress  from  the  centre  to  the  circum- 
ference, extends  its  ravages  to  the  textures  exterior  to  the  mamma. 
The  patient,  who  began  by  feeling  a sort  of  disagreeable  itching  or 
tickling  sensation  in  the  breast,  with  a sense  of  heat  and  pricking, 
now  experiences  deep  dull  pains,  which  next  become  lancinating, 
and  which,  felt  and  lost  by  turns  with  the  rapidity  of  lightning,  are 
compared  to  the  thrusts  of  a needle  or  a sharp  pen-knife,  suddenly 
forced  through  the  breast.  The  skin  covering  the  scirrhous  indura- 
tion becomes  of  a rose  tint,  has  a polished  appearance,  and  is  tense; 
the  subcutaneous  veins  become  nodose,  distended  with  blood,  and 
perfectly  distinct ; the  nipple,  which  is  attached  to  the  glands  by  the 
galactophorous  tubes,  and  also  by  a resisting  tissue,  being  unable  to 
follow  the  growth  of  the  tumour  towards  the  exterior,  remains  buried 


CANCER  OF  THE  BREAST. 


443 


within  a sort  of  pit,  and  in  many  instances  becomes  at  last  completely 
effaced  as  the  surrounding  parts  project  more  and  more. 

The  malady,  which  ceases  not  its  onward  progress,  soon  changes 
its  features,  and  exhibits  itself  in  its  distinctive  characters,  sapping, 
more  or  less  furiously,  the  life  of  the  unfortunate  victim  of  its  attack. 
Now  is  the  period  arrived  when  the  pain,  becoming  more  frequent 
and  atrocious,  and  acquiring  increased  violence  during  the  evenings 
and  nights,  prevents  the  patient  from  tasting  of  repose,  and  introduces 
a general  perturbation  of  the  economy.  The  tumour  shows  some 
points  more  raised  than  the  rest,  and  quite  in  relief  above  the  surface ; 
the  skin  that  covers  each  of  these  reliefs,  and  that  has  taken  on  a 
deep  red  or  livid  hue,  grows  thin,  cracks,  and  is  covered  with  fissures 
which  discharge  an  ichorous  serosity,  the  colour  and  fetor  of  which 
vary,  while  its  acrimony  inflames  and  even  ulcerates  the  neighbour- 
ing parts.  These  fissures  and  ulcerations  increase  iff  size,  and 
gradually  approaching  nearer  and  nearer  to  each  other,  are  at  last 
fused  into  one  horrible  ulcer,  whose  edges  roll  outwards,  while  they 
constantly  grow  thicker  and  harder.  An  ulcerated  cancer  of  the 
breast  that  has  reached  this  stage,  exhibits  a knotty,  grayish,  wan- 
looking  surface,  which,  in  some  instances,  overspreads  itself  with 
reddish  fungous  vegetations,  secreting  a sanious,  and  generally  very 
foetid  fluid.  Lastly,  frequent  attacks  of  haemorrhage,  arising  from 
the  erosion  of  the  vessels,  sometimes  assist  in  diminishing  the  severity 
of  pain,  but  for  the  most  part,  these  sanguine  discharges,  instead  of 
doing  any  good,  only  serve  to  exhaust  the  remaining  strength  of  the 
patient. 

Upon  reaching  this  stage  the  disorder  is  no  longer  local,  and  those 
general  phenomena  begin  now  to  manifest  themselves,  whose  en- 
semble constitute  the  cancerous  cachexy.  Thus,  the  patient,  who 
loses  her  freshness  and  her  embonpoint,  and  whose  skin  takes  on  a 
yellow  straw-colour,  is  now  tormented  with  a dry  and  frequent 
cough,  attended  with  heat  arid  gnawing  pain  behind  the  sternum; 
she  is  agitated  with  febrile  paroxysms,  suffers  under  extreme  anxi- 
ety, a distressing  oppression,  a great  disgust  for  food,  obstinate  con- 
stipation alternately  with  purging,  and  in  fine,  she  has  most  of  the 
general  symptoms  denoting  the  cancerous  cachexy,  treated  of  in  our 
article  on  cancer  of  the  womb.  We  should  mention,  that  the  sub- 
clavicular  glands  begin  to  swell,  and  those  of  the  neck  and  axilla 
which  have  also  swollen,  become  knotty  and  scirrhous.  The  arm 
corresponding  to  the  diseased  side,  in  some  cases  becomes  cedematous, 
tense,  painful,  and  incapable  of  motion.  We  have  seen  a cancerous 
degeneration  of  the  mammse  invade  not  only  the  pectoral  muscles, 
but  even  expose  the  ribs  and  extend  its  ravages  to  the  pleura  costalis, 
which  had  itself  become  exposed,  thickened  and  fungous. 

Cancer  of  the  breast  does  not  always  pursue  the  development  and 
march  we  have  here  pointed  out.  Instead  of  always  commencing 
as  a small  hard  rounded  tumour,  situated  in  the  true  parenchyma  of 
the  mammary  gland,  or  in  the  adipo-cellular  tela  surrounding  it,  it 
invades  suddenly,  and  almost  at  once,  a great  part  or  even  the  whole 
of  the  breast.  This  form  of  cancer  has  been  observed  in  very  fat 
women,  who  have  attained  to  the  period  of  change  of  life.  The 


444 


CANCER  OF  THE  BREAST. 


tumour,  which  occupied  the  entire  breast,  is  a little  flattened,  hard, 
movable  with  the  rest  of  the  breast,  but  not  rolling.  The  skin  above 
it  is  always  thicker  than  natural,  and  is  united  to  it  by  so  dense  a 
cellular  tela,  that  it  is  not  possible  to  make  it  slide  over  the  surface 
of  the  induration,  or  to  pinch  it  up  from  the  surface  with  the  fingers. 

As  these  changes  in  the  density  and  size  of  the  breast  mostly  take 
place  in  the  beginning,  without  giving  rise  to  any  pain  at  the  time, 
the  woman  does  not  discover  it,  for  the  most  part,  until  the  size  of  the 
breast  has  considerably  augmented,  or  until  a clear  bloody  serosity, 
escaping  from  the  nipple,  happens  to  soil  her  dress.  The  nature  of 
the  evil  soon  leaves  no  uncertainty  on  the  mind ; the  teguments  of 
the  indurated  breast,  after  having,  for  some  length  of  time,  preserved 
their  colour,  assume  a darker  cast,  and  exhibit  certain  tortuous  emi- 
nences produced  by  the  blackish  varicose  veins  of  the  part ; the  pain, 
which  was  at  first  tensive,  soon  grows  into  lancinating  pain.  The 
mammary  globe,  whose  size  and  density  have  gone  on  increasing, 
exhibits  upon  its  surface  those  knotty  protuberances  which,  by  ulce- 
rating, give  birth  to  the  symptoms  of  the  last  stage  of  cancer. 

The  cancerous  degeneration  of  the  breast  may  likewise  assume  the 
form  designated  by  writers  as  soft  cancer , which  forms  either  in  the 
gland,  or  in  the  adipo-cellular  tissue  about  it.  In  the  commencement, 
this  variety  is  not  only  less  hard  than  a scirrhus,  but  it  grows  also 
with  much  greater  rapidity.  It  is  also  distinguished  from  scirrhus 
by  knots  that  are  much  larger,  softer,  and  having  a sort  of  fluctua- 
tion. This,  moreover,  is  the  form  of  cancer  that  is  most  likely  to 
retain  its  indolence,  and  in  which  the  vessels  also  are  most  dilated. 
When  the  tumour  has  attained  a certain  size  it  adheres  more  and 
more  closely  to  the  skin,  which  grows  red  and  violaceous  as  to  tint, 
and  admits  of  our  perceiving  a much  more  decided  fluctuation.  If 
a cutting  instrument  be  plunged  into  the  centre  of  the  softened 
portion,  a bloody  serum  flows  out ; when  the  tumour  opens  sponta- 
neously, there  generally  springs  from  the  opening  a fungus  like  a 
mushroom,  which  sometimes  strangulates  itself  and  falls  off,  which 
makes  the  patient  suppose  herself  to  be  cured,  until  one  or  several 
such  vegetations  come  to  dispel  her  consolatory  illusions. 

[I  saw  such  a cancer,  which  protruded  in  the  breast  of  a primiparous 
young  lady.  The  tumour  had  been  noticed  eighteen  months  before  her 
marriage.  The  lactation  developed  the  malady.  It  came  out  like  a mush- 
room, and  was  removed  at  the  base  of  a sort  of  pedicle,  by  a ligature  applied 
bv  my  distinguished  townsman,  Dr.  J.  Rhea  Barton.  The  cure  is  complete. 
She  has  been  confined  again,  and  nurses  her  child  without  any  menace. — M.] 

It  also  happens,  in  some  cases,  that  the  tumour  is  formed  by  a great 
cyst,  containing  from  three  to  six  ounces  of  bloody  serosity ; the  walls 
of  the  cyst,  which  are  generally  smooth,  resemble  a serous  surface, 
and  present  at  some  point  one  or  more  fungi.  This  form  of  encysted 
degeneration  is  the  least  mischievous,  and  least  subject  to  relapse, 
because,  when  the  cyst  is  taken  away,  the  disease  is  destroyed. 
Where  the  cancerous  tumour  is  not  encysted,  which  is  incomparably 
the  most  frequent  case,  the  diseased  tissue,  some  portions  of  which 


CANCER  OF  THE  BREAST. 


445 


resemble  that  of  the  spleen,  is  blended  with  the  healthy  tissues,  and 
this  variety,  a most  dangerous  one  of  mammary  cancer,  often  termi- 
nates by  gangrene. 

We  ought  still  to  treat  of  a variety  described  by  Lassus:  this  author 
says,  ( Pathol . Chirurg.  t.  i.,)  that  there  are  some  women,  in  whom, 
at  the  age  of  forty  or  fifty  years,  the  two  breasts  suddenly  become 
voluminous  and  as  hard  as  marble.  The  tumefaction  and  hardening 
extend  to  the  shoulders  and  front  of  the  chest,  the  skin  is  reddish 
and  marked  with  lines,  the  pain  is  excessive,  the  patient  experiences 
considerable  difficulty  of  respiration,  and  may  perish  prior  to  the 
ulceration  of  the  tumour.  It  is  to  this  variety  that  Professor  Alibert 
has  assigned  the  name  cancer  tburne. 

Finally,  in  some  subjects,  it  is  not  the  cellular  tissue  or  glandular 
portion  of  the  mammae,  which  is  primarily  affected,  but  the  skin 
which  covers  them ; then  are  developed  here  and  there  upon  the 
surface  of  the  integuments  of  the  breast  hard,  rounded  tubercles,  of  a 
violet  colour,  increasing  gradually  in  number  and  size,  and  blending 
together  little  by  little  as  they  approach  each  other.  The  skin  be- 
comes hardened  and  wrinkled,  and  retracts  upon  the  dried  mamma. 
Lancinating  pains  come  on,  the  axillary  glands  become  engorged, and, 
before  long,  the  disease  produces  its  accustomed  ravages.  This  variety 
is  allied  to  that  which,  according  to  Boyer,  occurs  at  the  critical  age, 
and  in  which  the  breast,  instead  of  being  engorged,  becomes  hardened 
and  shriveled  from  assuming  a firm,  compact  consistence  in  one  or 
more  points  of  its  circumference.  The  indurated  mamma,  in  this 
form,  adheres  so  firmly  to  the  subjacent  parts,  as  to  become  entirely 
immovable,  and  seems  attached  by  a very  hard  cord  to  the  nipple, 
which  has  almost  diappeared.  Pouteau,  ( (Euvres  Posthumes,  t.  i.,) 
who  likewise  speaks  of  this  variety  of  cancer  of  the  breast,  regarded 
it  as  the  most  intractable  of  all.  The  progress  and  duration  of  cancer 
of  the  mamma  vary  greatly  in  different  cases ; we  think  it  should 
be  divided  into  acute,  chronic  and  stationary  cancer ; the  first 
rapid  in  its  progress,  and  lasting  from  three  to  six  months ; when  a 
relapse  takes  place  after  the  operation,  it  generally  shows  itself  before 
the  cicatrization  of  the  wound  produced  by  the  removal  of  the  tu- 
mour. Fabricius  Hildanus  states  that,  in  the  space  of  four  months, 
a cancer  destroyed  the  whole  of  the  breast  and  the  neighbouring 
parts.  Professor  Roux,  ( Melanges  de  Chirurgie,  p.  165,)  speaks  of 
having  seen  the  breast  of  a woman,  at  the  critical  period  of  life, 
enlarge  considerably  and  become  covered  with  cancerous  ulcerations, 
which  caused  death  in  less  than  three  months.  Chronic  cancer  is 
slow  in  its  progress,  and  may  last  several  years;  it  does  not,  in  gene- 
ral, relapse  until  after  the  cicatrization  of  the  wound.  Finally,  station- 
ary cancer , which  is  more  rare  than  the  preceding,  passes  through  its 
stages  so  slowly,  that  patients  retain  it  during  a greater  or  less  num- 
ber of  years,  and  sometimes  during  a lifetime,  as  they  often  perish 
at  an  advanced  age,  of  some  disease  independent  of  the  cancer.  We 
may  add,  that  the  progress  of  the  mammary  degeneration  under  con- 
sideration, is  more  rapid  in  proportion  as  the  tumour  is  larger,  softer, 
and  more  painful,  and  that  those  which  relapse  after  an  operation 
have  a very  rapid  course  always.  Let  us  remark,  lastly,  that  cancer 


446 


CANCER  OF  THE  BREAST. 


of  the  breast,  like  the  different  engorgements  of  that  organ,  some- 
times seems  to  augment  periodically  at  epochs  corresponding  to  the 
menstrual  function.  The  pain  and  the  tumour,  which  augment  with 
each  return  of  the  menses,  diminish  sensibly  during  the  interval.  It 
may  be  well  to  remark,  that  the  momentary  improvement  which 
takes  place  at  those  periods,  is  generally  attributed  to  the  effect  of 
some  new  treatment,  the  good  effects  of  which  are  always  too  hastily 
proclaimed. 

The  termination  of  cancer  of  the  breast,  when  left  to  itself,  is 
almost  constantly  in  the  death  of  the  patient,  which  is  generally  de- 
termined by  the  general  symptoms,  constituting  the  cancerous  ca- 
chexia. The  woman  may  perish,  also,  before  the  disease  has  passed 
through  all  its  stages,  from  some  complication;  such,  for  example,  as 
acute  or  chronic  pleurisy,  hydrothorax,  or  general  dropsy;  some 
dangerous  affection  of  the  intestinal  canal,  and  finally  gangrene, 
which  often  attacks  the  mammae  ; the  last  complication,  which  gene- 
rally renders  the  prognosis  still  more  unfavourable,  may,  in  some 
very  rare  cases,  become  a mode  of  cure  by  separating  the  diseased 
from  the  healthy  parts ; unfortunately,  this  mode  of  termination  does 
not  preserve  from  relapse,  and  the  hope  of  radical  cure  it  gives 
rise  to,  is  often  ephemeral.  The  spontaneous  cicatrization  of  cancer, 
without  surgical  treatment,  of  which  MM.  Nicod,  Bayle  and  Cayol, 
cite  examples,  is  a termination  still  more  rare  than  the  preceding. 

The  diagnosis  of  mammary  cancer  is  often  obscure,  especially  at  the 
commencement  of  the  disease  ; an  encysted  tumour,  with  a hardened 
base,  for  example,  has  sometimes  been  taken  for  scirrhus,  but  this 
mistake  is  of  no  great  consequence  to  the  patient ; for,  extirpation 
is  equally  indicated  in  both.  There  have,  likewise,  been  confounded 
with  scirrhus  of  the  breast,  not  only  the  fibro-cartilaginous  tumours, 
which  are  sometimes  developed  there,  but  also  chronic,  venereal, 
scrofulous,  milky,  and  herpetic  engorgements,  etc.,  which,  in  some 
cases,  undergo  the  cancerous  degeneration.  These  mistakes  might 
almost  always  be  avoided  by  referring  to  the  preceding  history  of 
the  patient,  by  tracing  the  march  of  the  disease,  and  especially  by 
recalling  the  diagnostic  signs  which  we  are  about  to  point  out  as 
peculiar  to  the  cancerous  induration  of  the  breast! 

We  may  affirm,  without  fear  of  mistake  once  in  a thousand  cases, 
that  we  have  a scirrhous  induration  of  the  mamma,  when  we  meet 
Avith  a tumour  seated  upon  some  part  of  that  organ  which  is  hard, 
unequal,  indolent,  insensible  to  pressure,  which  has  existed  for  more 
than  a year,  resisted  the  treatment  for  chronic  inflammations  and 
for  scrofulous,  milky  and  herpetic  indurations,  etc. ; which  has 
become  the  seat  of  sudden  lancinating  pains ; and  lastly,  which  is 
quite  indolent  and  insensible  during  the  intervals  between  the  pains, 
which  may  be  compared  to  the  pricking  of  needles. 

The  prognosis  depends  upon  the  nature  of  the  disease;  the  stages 
through  which  it  has  passed;  the  complications;  the  age  and  tempera- 
ment of  the  patient;  in  a word,  upon  all  the  circumstances  that  may 
exert  a favourable  or  unfavourable  influence.  When  the  patient  is  of 
strong  constitution,  young,  well  regulated,  affected  with  a scirrhus  in 
the  first  stage,  which  lias  been  developed  under  the  influence  of  some 


CANCER  OF  THE  BREAST. 


447 


external  cause,  the  prognosis  is  as  favourable  as  it  can  be.  The 
disease  resists,  with  great  obstinacy,  all  curative  means,  when  the 
patient  is  irritable,  nervous,  melancholy  or  hypochondriacal.  When 
the  tumour  is  voluminous,  adherent,  extended,  irregular,  lancinating, 
softened  in  some  points,  and  especially  when  it  has  been  developed 
spontaneously  about  the  critical  age,  the  prognosis  becomes  more 
unfavourable ; but  it  is  still  more  unfortunate  when,  to  these  symp- 
toms, are  added  considerable  engorgement  of  the  axillary  glands, 
dyspnoea  and  cough ; and,  to  conclude,  no  hope  remains  when  the 
general  symptoms  are  marked ; when  the  disease,  after  having  passed 
rapidly  through  its  stages,  still  exerts  an  injurious  influence  upon  the 
constitution,  and  the  tumour,  ulcerated  to  a great  extent,  furnishes  an 
abundant  sanious  and  fetid  suppuration. 

As  the  treatment  of  cancer  of  the  breast  has  for  its  object  not 
merely  to  combat  this  affection  after  its  development,  it  ought,  there- 
fore, to  be  divided  into  the  conservative , curative  and  palliative.  The 
preservative  treatment  consists  in  preventing  and  combating,  by  the 
most  suitable  means,  certain  diseases  and  derangements  of  the  func- 
tions which,  in  the  opinion  of  the  best  practitioners,  may  prove  to  be 
the  sources  of  cancer — amongst  others,  suppression  of  the  menses, 
scrofulous,  milky,  herpetic  and  venereal  engorgements,  and  the  differ- 
ent acute  and  chronic  inflammations  of  the  breast.  The  conservative 
treatment  of  cancer  of  the  mamma  is  nothing  more,  therefore,  than 
the  curative  treatment  of  the  pre-existing  disease.  It  is  by  this 
method  that  the  most  distinguished  practitioners,  having  dissipated, 
by  general  and  local  antiphlogistics,  and  by  resolvents,  etc.,  the  chronic 
engorgements  of  the  breast,  have  asserted  positively  as  to  their  hav- 
ing cured  tumours  of  a cancerous  nature,  when,  in  fact,  they  have, 
in  almost  all  the  cases,  merely  prevented  them. 

While,  in  our  opinion,  confirmed  cancer  is  incurable  by  the  re- 
sources of  medicine  alone,  properly  so  called,  we  believe,  founding 
upon  our  own  experience,  and  upon  the  observations  of  a great  num- 
ber of  physicians,  amongst  others  Hippocrates,  Galen,  Fearon,  Le- 
dran,  Vacher,  Pouteau,  Hufeland,  Marc-Antoine-Petit,  of  Lyons, 
Lisfranc,  Recamier,  and  Lallemand,  of  Montpellier,  etc.,  we  believe, 
we  repeat,  that  it  is  possible,  and  when  the  disease  is  not  of  long 
standing,  to  obtain  the  resolution  of  certain  hard  engorgements  of  the 
breast,  which,  without  our  being  able  to  affirm  them  truly  scirrhous, 
since  their  dissection  cannot  be  made,  offer  at  least  the  strongest 
analogy  to  tumours  of  this  nature,  and  often  present  perfectly  identi- 
cal characters. 

The  treatment  of  scirrhous  tumours  of  the  mammae  consists  in 
removing  the  causes  which  may  have  produced  them,  if  we  can  suc- 
ceed in  discovering  these  causes,  and  then  resorting  to  the  methodical 
employment  of  the  different  means  we  are  about  to  point  out.  If 
the  woman  be  young  and  plethoric,  we  should  firs!  order  a general 
bleeding,  which  may  be  repeated  several  times,  if  the  disease  be  in 
the  acute  stage,  and  then  make  applications  of  leeches  about  the 
tumour,  which  should  afterwards  be  covered  with  an  emollient  poul- 
tice, sprinkled  with  laudanum.  Fumigations  of  elder-flower  water, 
the  bath,  demulcent  drinks,  mild  regimen,  frictions  of  the  skin,  dia- 


448 


CANCER  OP  THE  BREAST. 


phoretic  infusions,  residence  in  a dry  and  well-aired  situation,  gaiety, 
quiet  and  agreeable  amusements,  moderate  exercise,  with  the  pre- 
caution of  avoiding  violent  movements  of  the  superior  extremity  cor- 
responding to  the  diseased  gland,  and  lastly,  a perfect  execution  of 
all  the  functions  of  the  economy,  will  contribute  very  much  to  the 
resolution  of  the  induration. 

After  employing  these  various  means  for  some  length  of  time, 
should  we  find  that  the  tumour  has  ceased  to  diminish  and  is  no  longer 
painful,  it  will  be  well  to  make  use  of  discutients  and  resolvents,  with 
the  precaution,  however,  of  associating  them  at  first  with  emollients, 
lest  they  determine  too  acute  an  inflammation.  We  should  employ 
poultices  of  flax-seed  and  of  Windsor- beans,  made  with  simple  water 
at  first,  and  then  with  elder-flower  water,  infusion  of  chamomile, 
soap  and  water,  in  succession,  and,  finally,  with  a mixture  of  Goulard’s 
lotion,  or  decoction  of  roses  and  red  wine.  The  discutients  should 
be  succeeded  by  other  more  active  agents,  such  as  the  ammoniacat 
liniments,  plasters  of  camphorated  soap,  of  cicuta,  vigo  cum  mercu- 
rio-plaster,  frictions  of  mercurial  ointment  or  ointment  of  hydriodate  of 
potash,  fumigations  of  vinegar,  ammonia,  cinnabar  and  juniper  ber- 
ries, and,  lastly,  bags  of  fine  linen,  containing  muriate  of  ammonia, 
thoroughly  dried  and  reduced  to  powder.  We  should  prescribe,  at 
the  same  time,  the  internal  use  of  aperients  and  bitters,  amongst 
others  the  expressed  juices  of  succory,  of  fumitory,  and  of  bugloss, 
tisans  of  water-dock,  of  soap  wort,  and  of  scabiosa,  to  which  may 
be  added,  from  time  to  time,  suitable  quantities  of  sulphate  of  mag- 
nesia and  of  soda,  the  use  of  Seidlitz  water,  or  of  some  other  mild 
laxative,  which,  producing  a transient  excitation  of  the  digestive 
tube,  will  promote  the  resolution  and  concur  in  augmenting  the 
efficacy  of  the  other  remedies.  The  application  of  a swan  or  rabbit 
skin,  is  likewise  useful  in  maintaining  the  breast  at  a uniform  tempe- 
rature and  in  a state  of  moisture  usually  very  favourable.  We  add, 
also,  that  in  most  of  the  cases,  we  may,  like  M.  Lisfranc,*  after  the 
antiphlogistics,  and  in  combination  with  the  resolvents  and  discu- 
tients, make  use  of  local  excitants,  such  as  frequently  repeated  appli- 
cations of  a few  leeches,  say  from  three  to  six,  used  alternately  with 
small  moxas  of  three  or  four  lines  in  diameter,  or  very  small  blisters 
placed  about  the  mamma. 

Compression,  brought  into  use,  in  France,  by  M.  Biett,  after  having 
been  employed,  first  in  England,  by  M.  Young,  and  then  by  M.  Pear- 
son, and  Doctor  Ch.  Bell,  who  rejected  it,  and,  in  a report  which  he 
made  in  the  name  of  the  Medical  Committee  of  Middlesex,  de- 
scribed it  as  always  injurious, — compression,  we  repeat,  is  likewise 
a means  which,  combined  with  some  of  those  we  have  pointed  out, 
constitutes  a new  mode  of  treatment  fully  deserving  of  the  attention 
of  physicians.  Though  this  method,  from  which  M.  Recamier  has  ob- 
tained good  effects,  has  failed,  and  could  not  even  be  borne  by  many 
of  the  patients,  it  has,  nevertheless,  effected  cures  in  several  cases 
that  were  even  despaired  of,  or  has,  at  least,  very  much  facilitated 

* In  the  inaugural  dissertation,  (No.  68,  May  1, 1826,)  Doctor  Corbin  has  published 
several  cases,  proving  the  efficacy  of  M.  Lisfranc’s  method,  the  happy  results  of 
which  we  have  ourselves  been  able  to  appreciate. 


CANCER  OF  THE  BREAST. 


449 


the  extirpation  of  the  disease,  either  by  reducing  the  tumour  to  a 
small  size,  or  by  rendering  it  movable,  and  isolating  it  from  the  parts 
with  which  it  had  formed  adhesions. 

This  treatment  consists  in  the  application  of  permanent  pressure, 
continued  during  a certain  period,  to  the  mamma  affected  with  cancer 
in  its  different  stages,— even  in  the  state  of  ulceration,  which,  in  this 
case,  however,  must  first  be  cauterized,  so  as  to  produce  a slough  of  all 
the  affected  parts,  and  allow  of  the  subsequent  approximation  of  the 
edges  of  the  wound  with  adhesive  strips.  As  it  would  take  too  long 
to  describe  M.  Recamier’s  bandage  in  detail,  we  shall  be  satisfied 
with  saying  that  it  is  composed  of  one  long  roller  and  of  several  discs 
of  agaric  interposed  between  each  turn,  in  such  a way  as  to  enclose 
the  tumour  gently  and  equally,  and  form  a truncated  cone,  the  base 
of  which  covers  the  whole  breast,  and  the  apex  corresponds,  as 
nearly  as  possible,  to  the  centre  of  the  induration. 

In  order  to  avoid  compressing  the  whole  circumference  of  the  tho- 
racic parietes,  so  generally  and  violently,  and  with  the  view  of 
acting  more  directly  upon  the  whole  tumour,  without,  in  anyway, 
pressing  the  healthy  breast,  we  invented,  ten  years  since,  a mechani- 
cal bandage,  which  may  be  applied  and  removed  in  a few  minutes. 
This  compresser,  by  establishing  a local  pressure,  which  the  physician 
and  the  patient  can  augment  or  diminish  at  will,  by  means  of  a key, 
renders  the  method  much  more  supportable,  and  does  not  require, 
like  the  roller  bandage,  to  be  entirely  removed  when  the  compression 
becomes  painful  or  when  it  interferes  with  the  dilatation  of  the  tho- 
rax, and,  consequently,  with  respiration.  Let  us  add  that  our  mam- 
mary compresser,  which, 

by  means  of  straps,  may  Fig.  44. 

remain  applied  while  the 
patient  is  in  bed,  as  well 
as  when  up,  requires,  like 
M.  Recamier’s  bandage, 
discs  of  very  soft  agaric 
of  different  sizes.  The 
instrument,  when  com- 
plete, is  composed  as  fol- 
lows : 1,  a hollow  elastic 
cushion,  ( pelote ,)  design- 
ed to  cover  pieces  of 
agaric  and  keep  them  in 
place,  upon  the  tumour ; 

2,  a girdle,  two  inches 
and  a half  wide  and  a 
yard  long,  arranged  with 
an  opening  or  fenester, 
to  be  enlarged  or  dimi- 
nished at  will,  so  as  to  re- 
ceive the  sound  breast, 
and  thus  entirely  avoid 
compressing  it ; 3,  a steel 
29 


450 


CANCER  OF  THE  BREAST. 


Fig.  45. 


Fig.  46. 


plate,  with  a screw  upon  its  external  surface,  by  turning  which  the 
cushion  may  be  forced  down  upon  the  diseased  breast.  On  one  side  is 
a cylinder,  with  a rachet  wheel,  by  turning  which  the  girdle  may  be 
lengthened  or  shortened,  at  discretion.  On  the  other  side  is  a six- 
tongue  buckle.  The  figure  (No.  44)  on  the  preceding  page  explains 
the  apparatus  adjusted  in  situ.  The  circular  pad,  or 
cushion,  is  represented  by  the  figure  annexed,  No.  45 ; 
and  the  form  of  the  steel  plate  is  designated  by  figure 
46,  which  is  also  annexed. 

M.  Recamier  does  not  always  employ  compression 
alone,  in  the  treatment,  and  exclusively ; for  exam- 
ple, he  commences  by  the  application  of  leeches,  by 
cauterization,  by  enucleation,  and  by  the  ligature, 
according  as  the  tumour  is  painful  and  inflamed,  or 
is  affected  with  ulcerated  scirrhous  masses  and  fun- 
gous vegetations.  Though  we  believe  with  the  dis- 
tinguished practitioner  we  have  just  cited,  that  com- 
pression often  renders  the  tumour  more  movable  and 
more  favourable  to  the  success  of  the  operation,  we 
are  of  opinion  that  it  ought  not  to  be  resorted  to  except 
when  the  induration  is  but  slightly  painful  on  pressure 
and  presents  no  solution  of  continuity.  We  ought  to  remark,  also, 
that  there  are  some  women  who  cannot  bear  compression  in  any 
mode  in  which  it  can  be  applied,  and  that  the  constant  attention, 
moreover,  which  it  necessitates  during  many  consecutive  months, 
may  lead  us  to  ask  whether  extirpation  would  not  be  preferable, 
even  though  the  compression  were  supportable  and  advantageous, 
and  examples  of  cure  more  numerous  than  those  which  the  science 
records.  For  ourselves,  we  are  of  opinion  that  when  the  patient  can 
support  compression,  it  is  well  to  employ  it,  as  well  as  all  other  means, 
before  deciding  upon  the  removal  of  the  cancerous  part. 

When  the  methodical  employment  of  the  internal  and  external 
means,  just  pointed  out,  brings  about  an  evident  diminution  of  the 
tumour,  their  use  may  be  persevered  in  as  long  as  they  continue  to 
act  favourably ; but,  should  the  induration  retain  its  consistence  and 
size,  and,  a fortiori , should  it  augment  in  size,  become  painful  and 
irregular,  and  at  length  become  ulcerated,  softened,  and  present  all 
the  characters  of  confirmed  cancer,  we  ought  to  renounce  the  hope 
of  obtaining  its  resolution,  and  abstain  thenceforth  from  fatiguing  the 
patient  by  a treatment,  the  inutility  of  which  is  manifest,  and  which, 
if  continued  for  a longer  time,  would  become  hurtful,  by  hastening 
the  progress  of  the  cancerous  degeneration. 

We  shall  not  attempt  to  exhibit  the  immense  list  of  substances 
which  have  been,  in  turn,  set  forth  for  the  treatment  of  ulcerated 
cancer : their  inutility,  now  generally  acknowledged,  is  a legitimate 
excuse  for  thus  passing  them  by.  We  shall  rest  satisfied  byrecalling, 
in  few  words,  the  therapeutical  means  which  have  more  particularly 
fixed  the  attention  of  physicians;  but  we  ought  to  inform  our  read- 
ers that  we  shall  pass  by,  in  silence,  the  internal  remedies  which 


CANCER  OF  THE  BREAST. 


451 


have  already  been  mentioned  in  onr  remarks  upon  cancer  of  the  uterus. 
Among  the  external  remedies  that  have  had  a more  or  less  deserved 
reputation,  we  cite,  first,  arsenic  employed  alone  or  united  with  other 
substances,  by  John  Gaddesden,  Valescus  of  Tarentum,  Fuchs,  Para- 
celsus, Reusner,  Jerome  Capivacci,  Pierre  Alliot,  Deidier,  Roosselot, 
Frere  Come,  Justamont,  the  celebrated  Dubois,  Messrs.  Zang,  Bug- 
niard  of  Lyons,  Grandpre  of  Givors,*  and  a number  of  others,  whom 
it  would  take  too  long  to  name. 

Lead  also  has  been  used  in  the  state  of  oxide  made  into  a plaster, 
by  Balthazar  Timee ; in  the  state  of  acetate  in  solution,  by  Goulard, 
Imbert,  Fearon,  Boyer  and  Pissier  ;t  and  finally,  in  the  metallic  state, 
by  means  Qf  a plate  covered  with  unguent,  diapompholigos , by  John 
Schmidt,  (a  drying  ointment,  composed  of  oil,  wax,  juice  of  night- 
shade, incense,  flowers  of  zinc,  and  oxide  and  sulphuret  of  lead. 
— M.)  Mercury,  in  the  state  of  proto  and  deuto-chloride,  has  also 
had  its  partisans;  amongst  others,  Bowman  and  Norford.  The  same 
is  true  of  the  carbonate,  the  phosphate  and  the  arseniate  of  iron,  re- 
commended by  Mr.  Carmichael ; of  the  sulphate  of  copper  and  the 
muriate  of  baryta;  and,  finally,  of  the  diluted  acids,  especially  the 
hydrochloric;  and  of  different  gases,  as  carbonic  acid,  (Peyrilhe, 
Evrart  and  Fourcroy,)  chlorine,  and  the  sulphurous,  mercurial  and 
arsenical  vapours,  (Grandpre.) 

The  vegetable  kingdom  has  likewise  furnished  a large  number  of 
external  pretended  anti-cancerous  remedies,  such  as  opium,  cicuta. 
(Stork,  Kapp,)  nightshade,  (Vesalius,)  belladonna,  (Lambergen,) 
cinchona,  (Dietrich,)  rasped  carrots,  (Sultzer,)  and  a number  of  other 
vegetable  substances.  In  the  animal  kingdom,  we  find  the  gastric 
juice  of  animals,  the  blood  and  flesh  of  cattle,  the  infusion  of  snails, 
and  especially  the  spawn  of  frogs,  whose  marvellous  efficacy  was 
vaunted  by  0.  P.  Braun.  Cauterization,  by  means  of  a hot  iron  or 
the  solar  rays  collected  by  a lens,  or,  finally,  with  different  escharo- 
tics,  such  as  arsenical  powder,  the  nitric  and  hydrochloric  acids,  chlo- 
ride of  antimony,  nitrate  of  silver,  and  the  acid  nitrate  of  mercury 
have  been  likewise  included  in  the  immense  list  of  external  therapeu- 
tical remedies  f 

* It  is  particularly  in  the  treatment  of  superficial  carcinomatous  ulcers,  that  M. 
Grandpre  has  proved  the  good  effects  of  arsenic  combined  with  sulphur,  and  espe- 
cially with  the  sulphuret  of  mercury,  (cinnabar,)  employed  chiefly  in  fumigations 
directed  upon  the  affected  surface,  which  is  isolated  by  means  of  an  apparatus  to 
prevent  the  respiration  of  the  poisonous  vapours.  Plunket’s  remedy  for  cancer  of  the 
breast  was  also  a combination  of  arsenic  and  sulphur;  but  he  added  a certain 
quantity  of  powdered  ranunculus,  and  used  the  mixture  merely  as  a topical  applica- 
tion. 

f M.  Pissier  combined  the  opium  with  the  oxide  of  lead,  and  Professor  Boyer  with 
the  acetate  of  the  same  metal. 

4 Of  all  the  caustics  employed  in  the  treatment  of  cancerous  affections,  there  is 
none  whose  use  has  been  more  general  than  that  of  Roosselot,  modified  by  the  cele- 
brated Dubois.  This  paste  is  composed,  of  dragon’s  blood,  an  ounce,  sulphuret  of 
mercury,  half  an  ounce,  and  arsenious  acid,  half  a drachm  ; which  must  be  pulver- 
ized and  well  mixed.  To  employ  these  substances,  it  is  necessary  to  moisten  them 
to  the  consistence  of  paste.  Dupuytren  employed,  with  advantage,  the  nitrate  of 


452 


CANCER  OF  THE  BREAST. 


Could  we  localize  the  disease  and  confine  its  action  to  the  degene- 
rated part,  nothing  would  be  easier  than  to  cure  cancer  of  the  breast, 
since  it  is  almost  always  possible  to  remove  it  completely.  Unfortu- 
nately, when  the  patient  decides  upon  the  operation,  this  is  no  longer 
the  case,  and  commonly  the  whole  economy  then  participates  in  the 
cancerous  affection.  It  is  from  hence  that  the  tumour,  when  re- 
moved, is  often  and  early  replaced  by  another,  even  before  cicatri- 
zation is  finished ; and  it  would  seem  that  the  disease  has  acquired 
new  force,  for  it  now  advances  with  hopeless  rapidity.  It  is,  there- 
fore, important  to  operate  too  soon  rather  than  too  late,  because, 
when  the  disease  is  confined  to  any  induration  of  small  extent,  and  is 
not  ulcerated,  we  shall  not  only  have  less  cause  to  fear  a relapse,  but 
the  tumour  to  be  removed,  being  small  and  movable,  will  require  an 
operation  of  little  importance,  whilst,  by  deferring  it,  the  degenera- 
tion, having  increased,  constitutes  a serious  disease,  strongly  disposed 
to  relapse,  and  requiring  a laborious  operation,  with  extensive  and 
deep  incisions. 

Though  Celsus,*  Archigenes,t  Albucasis,f  Pierre  Cerlata,§  Leonard 
of  Berfapaglia,||  John  Tagault,1F  Triller,**  Monro, tt  Reneaulme,l± 
Boyer, §§  Rouzet,||||  and  some  modern  surgeons,  are  amongst  the 
antagonists  of  the  extirpation  of  the  cancerous  breast,  we  believe 
with  Galen,1 IMF  Leonidas,***  Aetius,ttt  Paul  of  Egina,f±±  Avicen- 
na,§§§  Rhazes,||||||  Lanfranc/FHf  Scultetus,****  de  la  Vauguyon,tttt 
Heist.er,±ff±  Cheselden,§§§§  Verduc,||||||||  Ledran,11inF1F  Lecat,***** 

mercury,  prepared  in  the  following  proportions : crystallized  mercury,  four  drachms ; 
nitric  acid,  an  ounce.  M.  Recamier  often  makes  use  of  this  remedy,  or  of  a concen- 
trated solution  of  caustic  potash.  We  think  that  it  is  necessary  to  cauterize  deeply, 
so  as  to  attack  the  totality  of  the  cancer,  which,  when  not  completely  destroyed, 
reappears  with  great  rapidity  and  with  augmented  virulence. 

* Lib.  v.  cap.  18. 

j-  Aetius,  tetrab.  iv.  serm.  iv.  cap.  43. 
t Chirurg.,  lib.  i.  sect.  50. 

§ Philos.,  lib.  vii.  cap.  33. 
j|  Chirurg.,  tr.  i.  cap.  25. 
t Instit.  chirurg.,  lib.  i.  cap.  15. 

**  Haller,  diss.  chirurg.,  t.  ii.  p.  475. 
ij-  Edinburgh,  trans.  supplern.,  1752. 
tt  Non  ergo  mammte,  sect,  curand.  Paris,  1732. 

§§  Traite  des  malad.  chirurg.,  t.  vii.  p.  297,  1821. 

y Recherches  et  observat.  sur  le  trait,  du  cancer.  Paris,  1818,  1 vol.  in  8vo. 

^ * Method,  med.,  lib.  xvi. 

***  Aetius,  tetrab.  iv.  serm.  iv.  cap. 43. 
ttf  Toe.  cR->  caP*  42. 
ttt  Lib.  vi.  cap.  45. 

§§§  Canon.,  lib.  iv.  fen.  iii.  cap.  2. 

Continens,  lib.  xiii.  cap.  2. 

Chirurgia  parva,  tr.  i.  doct.  iii.  cap.  13. 

****  Armamentarium  chirurg.,  pars  i.  p.  22,  tab.  xiv.  et  tab.  xxxvi. 
fttt  Traite  comp,  des  operat.  de  chirurg.  chap.  xvii.  p.  163. 
tttt  Chirurg.,  t.  ii.  cap.  107. 

§§§§  Observ.  1749,  and  biblioth.  chir.  of  Haller,  t.  ii.  p.  24. 

IRUS  Operat.  des  chirurg.  et  pathol.,  t.  i.  chap.  15. 

Traite  des  operat.  de  chirurg.,  p.  375. 

*****  Biblioth.  chirurg.  de  Haller,  t.  ii.  p.  176. 


CANCER  OF  THE  BREAST. 


453 


Garengeot,* * * §  Dionis,t  J.  L.  Petite  Vacher,§  Siebold,||  Sabatier, 1 
Camper,** * * §§  Dessault,tt  Bell,tt  James  Hill,§§  and,  finally,  Scarpa, 
Dupuytren,  MM.  Roux,  Richerand,  Zang,  Cloquet,  Lisfranc,  S. 
Cooper,  Velpeau,  Sanson,  Begin,  Amussat,  and  a great  number  of 
other  distinguished  surgeons  of  our  epoch,  we  believe,  we  say,  that 
the  operation  should  always  be  attempted  when  none  of  the  contra- 
indications, about  to  be  mentioned,  exist. 

If  it  be  objected,  that  out  of  sixty  women,  whom  Monro  (loc. 
cit.)  saw  operated  upon,  four  only  had  no  relapse  at  the  end  of  two 
years;  if  we  are  told,  moreover,  that  the  celebrated  Boyer  (loc.  cit.) 
gives  an  equally  unfavourable  diagnosis,  since,  of  one  hundred  cases 
of  extirpation  of  cancerous  parts,  there  were  only  five  subjects  radi- 
cally cured,  we  will  oppose  the  testimony  of  James  Hill,  who,  in 
ninety-eight  cases  of  cancer,  saw  but  twelve  relapses  ; and  we  might 
quote,  also,  Doctor  North,  who  has  remarked  but  few  cases  of  failure 
in  more  than  one  hundred  examples.  Finally,  to  a large  number  of 
other  authentic  facts,  establishing  radical  cqres,  we  might  add  the 
observation  of  Zeller,  of  Zellemberg,||||  who,  in  1810,  amputated  with 
entire  success,  a cancerous  breast  of  more  than  two  feet  in  diameter, 
and  that  not  less  singular  case  of  F.  T.  Ochmer,H1[  who  likewise  re- 
moved successfully  a cancerous  mamma,  weighing  ten  pounds,  from 
a pregnant  woman  who  was  delivered  without  accident,  and  reco- 
vered perfectly.  Finally,  we  cite  the  ablation  of  two  mammas,  per- 
formed with  success  on  the  same  female,  by  Foubert,***  and  the 
same  operation  performed  a few  years  since  by  MM.  Thuillier  and 
Thibaultjttf  at  the  hospital  of  Limoges,  on  a girl  twenty-two  years 
of  age,  both  of  whose  mammas  were  attacked  with  a scirrhous 
degeneration.  These  organs  were  so  much  tumefied  that  they 
weighed  about  twenty-nine  pounds,  and  had  been  only  four  years  in 
attaining  this  extraordinary  size.  The  mamma  removed  at  the  first 
operation  weighed  fourteen  pounds  and  a half,  and  the  cicatrization 
of  the  wound  did  not  occur  until  after  seventy-five  days.  The 
second  mamma,  the  weight  of  which  equaled  that  of  the  first,  was 
removed  three  months  afterwards,  and  union  was  obtained  in  fifteen 
days. 

Without  wishing  to  describe,  or  even  indicate  all  the  methods 
proposed  or  employed  by  authors  for  the  extirpation  of  cancer  of  the 
mamma,  we  are  about  to  confine  ourselves  to  the  description  of  the 
operation,  as  it  is  performed  by  most  surgeons  of  our  period,  but  we 
shall  be  careful  to  point  out  the  different  modifications  which  may  be 

* Traite  des  operat.  chirurg.,  t.  ii.  cap.  vii.  art.  i. 

•j-  Cours  d’operat.  chirurg.,  dem.  v.  p.  381. 

t Traite  des  malad.  chirurg.,  t.  i.  chap.  iv. 

§ Dissert,  sur  le  cancer  des  mammeiles,  1740. 

|j  Huermann,  chirurg.  operat.  t.  ii.  cap.  20.  ^ Med.  operat. 

**  Gences  natur,  etc.,  p.  194. 

•j-f  GGuvres  chirurg.,  par  Bichat,  t.  ii. 

Treatise  on  the  Theory  and  Manag.  of  Ulcers,  part  ii.  sect.  viii.  Edinburgh,  1 778. 

§§  Cases  in  Surgery.  Edinburgh,  1772. 

Hl|  Abhandlung,  ueber,  etc.  Wien,  1810,  p.  194. 

Observ.  einer  scirrheusen,  etc.,  1774. 

***  Mem.  de  l’acad.  de  chirurg.,  t.  iii.  p.  118. 

fff  Dissert,  sur  le  cancer,  etc.,  par  M.  Gaudeix  Laberderie,  Paris,  9 Juillet,  1827. 


454 


CANCER  OF  THE  BREAST. 


Fig.  47. 


required  by  the  mobility,  small  size,  great  development,  or  adhesions 
of  the  tumour,  or  finally,  the  complete  degeneration  of  the  breast, 
and  the  different  complications  which  may  be  met  with. 

Mode  of  operating.  In  order  to  obviate  the  danger  of  syncope, 
and  that  the  surgeon  may  be  more  conveniently  placed  during  the 
operation,  we  think,  that  instead  of  seating  the  patient  on  a chair,  it 
is  better  that  she  should  lie  on  a bed  or  table,  arranged  in  such  a 
way  that  the  head  and  thorax  may  be  sufficiently  elevated  to  make 
the  breast  project  as  much  as  possible. 

When  the  tumour  is  circumscribed,  movable,  and  of  small  size,  it 
is  sufficient  to  make  a longitudinal  incision  in  the  breast  proportioned 
to  the  size  of  the  induration,  and  then  with  a 
double  hook,  or  still  better  with  the  much  more 
commodious  forceps  which  we  have  invented 
for  this  operation,  [vide  fig.  47,)  we  seize,  after 
having  separated  the  edges  of  the  incision,  the 
morbid  production,  and  draw  it  out  with  the 
left  hand,  while  the  right,  armed  with  a convex 
bistoury,  finishes  its  separation  and  detachment 
from  the  cellular  and  vascular  bands  to  which 
it  adheres.  When  we  have  arrested  the  flow 
of  blood  by  the  ligature  or  torsion,  the  edges 
of  the  wound  are  drawn  together  with  adhe- 
sive straps. 

Where  the  breast  is  very  much  developed, and 
particularly  if  the  tumour  were  large,  although 
circumscribed  and  movable,  it  would  be  ad- 
vantageous, according  to  the  advice  given  by 
Paul  of  Egina,*  not  to  preserve  all  the  integu- 
ment, but  to  excise  a larger  or  smaller  ellipsis 
of  it.  In  this  way,  the  operation  would  become 
not  only  easier  and  more  rapid,  but  would 
more  probably  be  successful,  because  the  lips 
of  the  wound  would  be  in  a condition  more 
favourable  to  nice  reunion,  than  if  all  the  integument  had  been  pre- 
served. In  case  the  skin  itself  should  be  altered,  thinned,  and  ad- 
herent to  the  tumour,  we  should,  with  still  greater  reason,  follow 
this  precept,  that  is  to  say,  remove  all  the  affected  parts  by  two 
semi-elliptical  incisions,  which  ought  always  to  include  a certain 
portion  of  the  healthy  tissue.  If  the  entire  breast  were  implicated, 
it  would  be  necessary,  after  the  precept  of  Pimpernelle,  Verduc, 
and  most  modern  surgeons,  to  circumscribe  the  organ  by  two  semi- 
circular incisions,  in  such  a way  that  the  large  diameter  of  the  wound 
might  be  directed  obliquely  from  above  downwards,  and  from  without 
inwards,  in  the  direction  of  the  fibres  of  the  great  pectoral  muscle,  the 
projection  and  tension  of  which  should  be  augmented  by  causing  an 
assistant  to  hold  the  arm  upwards  and  outwards. 

In  order  to  proceed  to  the  operation,  the  surgeon,  after  having 
caused  his  patient  to  be  arranged  in  the  mode  we  have  just  pointed 

* De  le  rned.,  lib.  vii.  cap.  46. 


CANCER  OF  THE  BREAST. 


455 


out,  should  draw  the  skin  of  the  breast  in  a direction  the  contrary  of 
the  first  semilunar  incision,  that  is  to  say,  the  inferior,  and  then  when 
this  is  finished,  he  should  draw  down  with  his  left  hand  the  parts 
to  be  extirpated,  and  making  an  assistant  tighten  the  integuments 
above,  he  should  insert  the  cutting  instrument  in  the  external  angle 
of  the  first  incision,  and  make  the  superior  incision,  which  he  will  ter- 
minate at  the  inferior  angle  of  the  wound,  of  which  it  will  complete 
the  ellipsis.  When  the  cancerous  mass  has  been  thus  circumscribed, 
he  will  seize  the  mass  to  be  removed  with  our  hook-forceps,  or  with 
a pair  of  Muzeux  forceps,  and  then  dissect  the  tumour  first  from 
below  upwards,  and  then  from  above  downwards,  taking  care  to 
leave  a portion  of  healthy  tissue  about  the  affected  gland;  if  the 
depth  of  the  disease  require  it,  he  should  not  fear  to  go  down  to  the 
muscular  fibres,  and  even  to  the  ribs. 

With  the  view  of  terminating  the  ablation  of  the  cancerous  tu- 
mour more  rapidly,  we  may  dispense  with  tying  the  arteries  as  they 
spring,  closing  their  orifices  by  the  fingers  of  an  assistant.  Should 
any  diseased  or  suspected  portions  have  escaped  the  instrument  at 
first,  it  would  be  necessary  to  extirpate  them  at  once  ; finally,  after 
having  tied  the  vessels  and  washed  the  wound,  the  operator  should 
approximate  the  edges  and  maintain  them  in  contact  with  the  thumb 
and  index  finger  of  each  hand,  while  an  assistant  applies  long  ad- 
hesive strips,  beginning  with  those  in  the  middle.  The  number  of 
these  strips  must  vary  according  to  the  extent  of  the  wound;  and 
small  intervals  should  be  left  between  each,  in  order  to  give  issue  to 
the  pus  and  other  secreted  fluids.  A pledget  covered  with  cerate, 
one  or  two  bundles  of  charpie,  and  long  compresses  maintained  by  a 
body  bandage,  complete  the  dressing  apparatus  required  in  this  ope- 
ration. 

Where  the  loss  of  substance  is  so  great  as  to  render  the  approxima- 
tion of  the  edges  of  the  incision  impossible,  or  at  least  very  difficult, 
it  would  be  well,  after  the  precept  of  M.  Lisfranc,  to  separate  each 
side  of  the  wound  from  the  subjacent  parts,  to  the  extent  of  one  or 
more  inches ; by  this  method,  we  procure  sufficient  integument  to 
unite  the  wound  directly.  In  case  we  should  not  wish  to  resort  to 
immediate  reunion,  the  adhesive  strip  would  become  useless,  and  it 
would  suffice  to  cover  the  wound  with  a piece  of  linen  spread  with 
cerate,  and  with  holes  cut  in  it,  and  some  pledgets  of  charpie  and 
several  compresses.  Should  there  exist  any  engorgement  of  the 
axillary  glands  of  a suspicious  nature,  we  should  prolong  the  upper 
angle  of  the  wound  as  far  as  these  glandular  indurations,  but  if  too 
distant,  it  would  be  better  to  effect  their  extirpation,  by  exposing  them 
by  independent  incisions ; finally,  if  we  had  reason  to  fear  lesion  of 
some  rather  large  vessels,  it  would  be  necessary,  after  having  pro- 
perly isolated  them,  to  tie  the  pedicle  of  the  engorged  glands,  and 
then  divide  it  in  front  of  the  ligature,  as  advised  by  J.  L.  Petit,  Des- 
sault,  Dupuytren,  Zang,  MM.  Lisfranc,  Velpeau,  and  other  distin- 
guished surgeons. 

In  case  the  wound  should  assume  an  unfavourable  appearance  a 
few  days  after  the  operation,  it  might  be  recovered  by  applications  of 
chlorinated  soda  or  wine  and  honey,  or  cauterization  with  nitrate  of 


456 


CANCER  OF  THE  BREAST. 


silver.  If  symptoms  of  purulent  absorption  should  suddenly  make 
their  appearance,  such  as  nausea,  rigors,  fever,  etc.,  it  would  be 
necessary  to  destroy,  as  soon  as  possible,  the  adhesions  under  which 
the  pus  has  accumulated,  and  then  introduce  a tent  to  prevent  the 
too  rapid  approximation  of  the  edges  of  the  wound.  We  should 
never  forget,  that  it  is  to  the  neglect  of  this  important  point  of  surgi- 
cal therapeutics,  that  we  must  ascribe  most  of  the  failures  in  removal 
of  the  breasts,  and  in  a number  of  other  operations. 

We  shall  conclude  by  saying  that,  if,  after  some  lapse  of  time,  any 
vegetations  or  small  tubercles  of  doubtful  nature  should  appear,  it 
would  be  necessary,  after  the  example  of  Lapoterie,  of  Frere  Come, 
of  Zang,  and  some  modern  surgeons,  to  destroy  them  as  soon  as 
possible,  either  with  a cutting  instrument,  with  fire,  or  some  caustic 
substance,  as  the  arsenical  paste,  acid-nitrate  of  mercury,  or  the  lapis 
infernal  is. 

Circumstances  that  contra-indicate  the  operation . Two  cir- 
cumstances may,  according  to  M.  Richerand,  contra-indicate  the 
operation  ; the  too  great  extent  of  the  local  degeneration,  and  a gene- 
ral cancerous  infection.  The  operation  ought  likewise  to  be  rejected 
in  cases  where  the  breast  is  immovable,  adherent  to  the  ribs,  and  as 
it  were,  cemented  upon  the  thorax;  when  its  progress  has  been  rapid, 
when  the  skin  is  tuberculous  for  some  distance  ; and  finally,  when 
the  glands  of  the  axilla  are  greatly  engorged,  even  as  far  as  the  very 
neighbourhood  of  the  great  vessels.  We  ought  to  remark,  however, 
that  this  latter  circumstance  may,  according  to  the  remark  of  Dupuy- 
tren,  depend  upon  a sympathetic  irritation,  which  ceases  when  its 
cause  has  been  removed.*  We  add,  that  extensively  ulcerated  can- 
cer, encephaloid  and  melanoid  cancer,  as  well  as  scirrhous  cancer, 
which  has  suddenly  invaded  the  whole  of  the  breast,  are  the  most 
disposed  to  a sudden  relapse.  On  the  contrary,  movable  scirrhous 
tumours,  which  are  recent  and  of  small  size,  hydatiform,  encysted, 
and  tuberculous  cancers,  offer  the  most  favourable  chances  for  the 
success  of  the  operation,  and  the  radical  cure  of  the  patient. 

Notwithstanding  the  example  of  Foubert,  reported  by  Ledran,t 
who  successfully  performed  on  the  same  female  and  on  the  same  day, 
the  amputation  of  both  mammae,  one  of  which  was  deeply  ulcera- 
ted, and  the  other  scirrhous ; notwithstanding  the  success  of  MM. 
Thuiller  and  Thibauld,  of  Limoges,  (see  page  453,)  we  regard  the 
simultaneous  existence  of  several  cancerous  tumours  in  different 
organs  as  being  almost  always  a contra-indication  to  the  operation. 
There  is,  likewise,  but  little  to  hope  for,  where  the  affection  is  heredi- 
tary, where  general  symptoms  of  cancerous  cachexia  exist,  or  where 
the  female  has  suffered  for  a long  time  from  considerable  derange- 
ments of  menstruation. 

Though  several  authors  assert  that  a relapse  is  a circumstance 
which  ought  always  to  remove  all  idea  of  a new  operation,  we  think 
that  the  chances  of  a cure  cannot  be  too  carefully  weighed,  before 

* It  is  in  cases  of  this  kind,  no  doubt,  that  Louis,  Dessault,  Assalini,  Soemmering, 
and  some  others,  have  successfully  extirpated  cancerous  tumours,  without  removing 
the  engorged  axillary  glands. 

t Memoires  de  l’Acad.  de  chirurg.  t.  iii.  p.  18. 


ENCYSTED  TUMOURS  OF  THE  BREAST. 


457 


abandoning  the  patients  to  their  unfortunate  fate ; for,  Morgagni, 
Sabatier,  Lacombe,  L.  M.  Pousse,  etc.,  have  succeeded  in  obtaining 
a complete  cure  after  a second  and  even  a fourth  operation. 

Palliative  treatment.  When  cancer  of  the  breast  is  not,  or,  at 
least,  is  no  longer  of  a nature  to  be  operated  upon,  or  when,  the  patient 
refusing  to  submit  to  the  operation,  a radical  cure  is  no  longer  to  be 
hoped  for,  the  physician  ought  to  seek  to  render  the  disease  more 
bearable,  and  to  check  its  progress  by  a palliative  treatment.  This 
treatment  consists  in  regimen,  and  in  the  internal  and  external  em- 
ployment of  various  remedies.  We  must  prescribe,  with  this  view, 
a milk-diet,  vegetable  substances,  white  meats,  and  sedative  drinks. 
As  it  is  a treatment  of  symptoms  that  must  be  instituted,  we  should 
seek  sometimes  to  recruit  the  strength  by  tonics  and  bitters,  at  other 
times  we  must  ease  the  pain  and  oppose  the  nervous  symptoms  by 
narcotics  and  antispasmodics,  administered  in  the  form  of  potions, 
pills,  enemata,  etc.  We  should  also  prescribe  fomentations  and  seda- 
tive applications,  especially  extract  of  opium,  dissolved  in  fluid  ace- 
tate of  lead  or  incorporated  with  a liniment  or  cerate  employed  as  a 
topical ; and  finally,  the  use  of  baths,  small  general  bleedings,  appli- 
cations of  leeches  around  the  mamma,  and  a number  of  other  means, 
which  must  vary  according  to  the  symptoms,  and  will  aid  in  conduct- 
ing the  patient  to  the  tomb  as  gently  as  possible.  Happy,  says  M. 
Richerand,  if  they  can  add  to  the  oblivion  of  their  ills  the  sweet 
illusions  of  hope. 

OF  ENCYSTED  TUMOURS,  AND  OF  DIFFERENT  KINDS  OF  CHRONIC 
ENGORGEMENT  OF  THE  MAMMA. 

There  are  two  kinds  of  encysted  tumour  of  the  breast ; the  one  con- 
tains a serous  fluid  in  cells  which  compose  the  tumour,  the  other  en- 
closes globular  hydatids.  In  the  beginning,  these  tumours,  which  grow 
very  slowly,  and  which  are  commonly  regarded  as  being  the  result 
of  a chronic  inflammation  of  the  breast,  are  not  painful  except  at  the 
approach  of  the  menstrual  evacuations.  After  some  time,  the  cyst 
becomes  fluctuating,  while  the  remainder  of  the  tumour  retains  its 
primitive  hardness,  and  we  do  not  observe  the  skin  covering  it  to 
change  its  colour,  until  it  begins  to  ulcerate  ; it  is  not,  indeed,  until  the 
period  when  the  ulceration  begins  to  take  place,  that  the  health  of 
the  patient  is  slightly  disturbed.  t 

These  tumours,  which  make  their  appearance  from  the  age  of 
fifteen  to  sixty,  without  our  being  able  to  discover  the  cause,  may  be 
either  multiple,  or  may  present  themselves  in  the  form  of  a simple  cyst. 
In  either  case,  they  are  radically  cured  by  extirpation ; yet  when 
there  is  a simple  cyst,  Sir  A.  Cooper*  has  sometimes  confined  him- 
self to  piercing  it  with  a lancet,  and  the  cure  has  then  taken  place 
from  the  adhesive  and  suppurative  inflammation  which  followed 
this  slight  operation. t Finally,  we  shall  add  that  though  these  mam- 

* The  Lancet,  vol.  ii.  p.  368-370. 

-{-We  think  that  puncturing  cannot  be  followed  by  cure  except  when  we  have  to 
do  with  an  acephalocyst  cyst;  in  the  serous  cysts,  the  fluid  is  always  reproduced  after 


45S 


ENCYSTED  TUMOURS  OF  THE  BREAST. 


mary  cysts  do  not  constitute  diseases  of  a severely  malignant  charac- 
ter, they  may  in  some  cases  degenerate ; therefore,  for  this  reason, 
and  especially  to  quiet  the  patient  and  satisfy  the  mind,  we  should 
not  hesitate  to  extirpate  them,  taking**  care  not  to  open  the  cyst, 
which  must  be  detached  from  its  adhesions  by  a minute  dissection. 
In  case  the  tumour  should  have  been  opened  and  should  have  con- 
tained nothing  but  a serous  fluid,  and  especially  where  we  are  not 
certain  of  having  removed  the  whole  of  the  cystic  sac,  it  would  be 
necessary  to  cauterize  the  internal  surface  of  the  wound,  in  order  to 
prevent  the  reproduction  of  the  disease. 

Fibrous  tumours  developed  in  the  mammas  resist  all  therapeutical 
means,  and  also  require  complete  extirpation,  by  means  of  the  knife. 
The  same  is  true  of  a sort  of  movable,  globular  tumours,  soft  to  the 
touch,  less  distinctly  circumscribed  than  the  scirrhous  and  fibrous 
tumours,  which,  like  the  preceding,  are  met  with  most  commonly  in 
women  having  all  the  appearances  of  fine  health.  These  tumours, 
which  are  a species  of  lupia,  rarely  pass  into  the  cancerous  state, 
though  they  may  become  rather  large,  varying  between  the  size  of  a 
pea  and  a large  billiard-ball ; they  are  generally  indolent,  and  do  not 
become  painful  except  at  the  periods  of  menstruation. 

The  mammae  are  also  subject  to  other  chronic  ulcerations,  which 
present  more  or  less  analogy  to  those  we  have  just  mentioned,  and 
from  which  it  is  important  to  distinguish  them,  because  it  is  not 
necessary  to  extirpate  them  in  order  to  obtain  a radical  cure  ; amongst 
the  affections  of  this  class  are:  1,  engorgement  resulting  from  dis- 
turbed menstruation;  2,  engorgement  of  the  lymphatic  vessels;  3, 
scrofulous  engorgement. 

The  engorgement  which  is  observed  after  some  disorder  in  the 
periodical  discharge  of  the  menstruse,  occurs  in  a portion  of  the 
breast,  and  is  met  with  most  frequently  at  the  age  of  from  fifteen  to 
twenty-five  years ; the  induration  which  results  is  always  very  pain- 
ful to  the  touch,  especially  at  epochs  corresponding  to  those  at  which 
the  menstruae  were  in  the  habit  of  appearing.  The  pain  in  the  breast 
is  then  so  much  augmented  that  it  often  extends  from  the  diseased 
mamma  to  the  arm,  and  even  to  the  fingers  of  the  same  side.  This 
kind  of  induration,  which  has  been  called  irritable  tumour  of  the 
breast , by  the  celebrated  Sir  A.  Cooper,  (loc.  cit.  p.  405,)  never  re- 
quires the  extirpation  of  the  breast,  and  h fortiori  as  it  is  resolved  as  if 
by  enchantment^  so  soon  as  we  succeed  in  restoring  the  menstrual 
function.  We  ought  to  say,  also,  that  the  absence  of  fluctuation,  of 
febrile  symptoms,  of  throbbing  pains,  and  the  commemorative  cir- 
cumstances, will  always  suffice  to  prevent  our  confounding  this  affec- 
tion with  an  abscess  of  the  breast. 

The  tumefaction  of  the  lymphatic  vessels  passing  from  the  breast 
to  the  axillary  glands,  commonly  yields  without  difficulty  to  bitter 
and  sudorific  drinks,  to  narcotic  fomentations,  and  to  mercurial  and 
iodine  frictions.  Finally,  scrofulous  tumours,  which  are  sometimes 

it  has  been  evacuated ; the  extirpation  of  the  tumour  is,  therefore,  the  only  means 
which  suits  all  cases. 


DISORDERS  OF  THE  MENSTRUATION,  ETC. 


4 53 


followed  by  ulcers  of  a cancerous  appearance,  from  which  they  may 
be  readily  distinguished  by  the  absence  of  shooting  pains,  by  the  little 
sensibility,  the  nature  of  the  suppuration,  etc.,  rarely  resist  an  anti- 
scrofulous  regimen  and  treatment,  especially  the  internal  and  external 
use  of  pharmaceutical  preparations  whose  base  is  iodine. 

We  must,  in  order  to  conclude  what  we  had  to  say  upon  engorge- 
ments of  the  mammae,  add  that  those  engorgements  which  we 
observe  after  abscesses  of  these  organs,  are  not  long  in  being  resolved 
under  the  influence  of  topical  bleeding  and  an  antiphlogistic  treatment 
methodically  employed.  As  we  shall  treat  of  abscesses  of  the  breast 
in  speaking  of  the  diseases  developed  after  parturition  or  during 
lactation,  we  shall  not  dilate  any  further  upon  the  subject  at  present. 


SECTION  FIFTH. 

CHAPTER  IX. 

LESIONS  OF  THE  FUNCTIONS. 

Of  derangements  of  menstruation,  of  uterine  haemorrhages  and  chlorosis,  and  of  the 
neuroses  peculiar  to  women. 

In  health  and  disease,  in  whatever  climate  she  may  exist,  and 
whatever  may  be  her  social  condition,  her  physical  and  moral 
constitution,  woman  is  under  the  dominion  of  a physiological  and 
mysterious  law,  that  strong  and  powerful  law  which  subjects  her, 
during  a certain  period  of  her  life,  to  a periodical  haemorrhage  from 
the  reproductive  organs.  This  function,  termed  menstruation,  which 
keeps  all  the  others  under  its  empire,  and  which  is  in  some  sort  the 
regulator  of  all  the  other  apparatuses  and  systems,  because  of  the, 
intimate  sympathies  existing  between  the  uterus  and  the  other 
organs,  constitutes  the  least  equivocal  sign  of  the  health  and  fecun- 
dity of  women.  Without  this  discharge,  says  Roussel,  beauty  either 
appears  not,  or  is  lost ; the  order  of  the  vital  movements  is  destroyed ; 
the  soul  falls  into  languor,  and  the  body  into  exhaustion.  Though  it 
be  true,  that  serious  diseases  have  been  known  to  pass  through  all 
their  stages,  without  any  appreciable  disorder  resulting  as  to  the  peri- 
odical discharge,  it  most  commonly  happens  that  menstruation  is 
notably  disturbed  when  the  health  undergoes  any  alteration,  and  we 
observe  derangements  of  the  function  to  influence  the  exercise  of  all 
the  others,  and  add  its  morbid  influence  to  those  which  already  exist. 

[As  M.  Colombat  appears  to  have  omitted  nearly  all  reference,  in  his 
pages,  to  the  now  received  and  approved  doctrines  on  the  causes  of  menstru- 
ation, and  its  diseases,  I shall  take  advantage  of  this  page  to  enter  a few  addi- 
tional observations,  which  I consider  as  a necessary  introduction  to  what  he 
has  here  written  on  the  subject,  though  I have  already  said  something  on  the 


460  DISORDERS  OF  THE  MENSTRUATION,  ETC. 

subject  at  p.  25  of  this  work.  I look  upon  the  modem  theory  as  a most 
important  one,  and  if  that  doctrine  should  become  regarded  by  my  brethren 
here  as  well  established,  I shall  rejoice  to  have  called  their  attention  to  it ; 
since  I conceive,  that  well-founded  notions  of  the  physiology  of  the  func- 
tions are  essential  to  any  competent  views  of  their  pathological  states,  or 
their  therapeutical  requirements  or  indications. 

It  appears  to  me,  that  under  the  ancient  theories,  or  rather  hypotheses, 
on  the  catamenia,  no  sound  practical  views  could  ever  be  acquired,  although 
it  is  true  to  say,  that  the  lapse  of  ages  had  left  in  the  hands  of  the  profession 
a variety  of  remedies  and  indications,  the  use  of  which  was  rather  em- 
pirical than  philosophical,  rather  customary  than  useful,  and  which,  though 
the  best  that  could  be  commanded,  wer^  for  the  most  part  found  to  be  incom- 
petent, uncertain  and  baffling,  as  confessed,  indeed,  by  the  celebrated  Cullen, 
at  the  conclusion  of  his  Essay  on  Emmenagogues,  in  his  work  on  the  Mate- 
ria Medica. 

# Happily,  at  the  present  day,  we  are  better  informed  upon  the  nature  and 
'causes  of  the  mensual  phenomena,  both  in  health  and  disease ; and  in  so 
far,  at  least,  better  prepared  to  fulfil  our  duty  to  the  patient. 

De  Graaff ’s  discovery  of  the  ovarian  vesicle  rested  without  therapeutical 
profit,  until  Purkinje,  by  the  invention,  in  the  unimpregnated  yolk,  of  the 
vesicle  named  after  him,  laid  the  foundation,  in  1825,  for  the  subsequent 
revelations  as  to  the  nature  of  the  real  ovum,  by  MM.  Coste,  Wagner, 
Schwann,  Wharton,  Jones,  Barry,  Bischoff,  and  the  other  micrographers, 
who  have  thrown  so  much  light  on  the  subject  within  the  last  ten  or  fifteen 
years. 

The  result  of  these  beautiful  investigations  has  been  the  discovery  of  a 
physiological  law  of  the  sex,  under  which  the  embryonic  germ  is  found  to 
be  developed,  and  brought  to  perfection  at  stated  intervals , corresponding 
nearly  with  the  revolution  of  the  lunar  period  of  twenty-eight  days  each ; 
one  ovum  being  ripened  every  month. 

The  yolk  that  bears  the  germ,  in  all  the  mammals,  is  contained  within 
the  Graafian  vesicle,  and  it  may  readily  be  found,  with  a good  lens,  in 
the  drop,  or  drops  of  liquid  that  escape  from  a ripe  vesicle,  upon  puncturing 
it  with  a lancet,  or  crushing  it  under  the  compresser  of  a microscope. 

The  substance  of  the  ovary,  or  its  stroma , is  found  to  contain  a vast 
multitude  of  small  points,  disseminated  within  its  structure.  Each  of  these 
points,  discoverable  only  by  the  aid  of  a microscope,  is  supposed  to  be  a 
rudimental  germ,  ready  to  commence  its  work  of  development  whenever  the 
proper  time  may  arrive,  in  its  series  or  turn ; and  it  proceeds  in  that  work 
by  such  degrees,  that  at  least  one  such  will  be  brought  to  full  and  complete 
maturity,  as  before  said,  once  a month,  as  long  as  the  menstrual  age  lasts,  and 
while  the  woman  enjoys  good  health.  Now,  as  the  microscopic  ovum  is 
contained  within  a double  capsule,  called  the  Graafian  vesicle,  it  happens  that 
the  containing  vesicle  expands,  and  grows  with  great  rapidity  during  the  lat- 
ter part  of  the  process ; it  continues  to  rise  from  the  central  or  internal  parts 


DISORDERS  OF  THE  MENSTRUATION,  ETC. 


461 


of  the  ovary  towards  the  surface,  distends  the  stroma,  puts  the  tunica  albu- 
ginea on  the  stretch,  and  finally  bursts  outwards,  discharging  its  fluid,  and 
the  ovum  in  that  fluid,  with  its  accompanying  retinacula,  or  granular  matter, 
into  the  cavity  of  the  belly,  or  in  case  of  impregnation,  into  the  fimbria  of  the 
Fallopian  tube,  by  which  it  is  conducted  to  and  lodged  in  the  womb,  to  con- 
stitute the  ovum  of  a gravid  uterus.  Now,  it  clearly  appears,  from  the  show- 
ing of  Robert  Lee,  of  London,  M.  Negrie#,  of  Angers,  M.  Gendrin,  of  Paris, 
and  M.  Raeiborski,  of  the  same  city,  and  many  others — I have  seen  it  with 
my  own  eyes — that  if  a woman  die  in  menstruating,  or  soon  afterwards,  there 
is  found  on  the  surface  of  the  ovary  a bloody  and  ragged  opening,  leading 
into  a small  pit  or  crypt,  in  which  is  frequently  found  a small  clot  of  blood, 
and  which  crypt  once  contained  the  fluid,  the  granules  and  the  ovum  of  the 
now  broken  Graafian  vesicle.  It  also  appears,  that  where  the  rupture  has 
recently  taken  place,  the  entire  ovary  is  found  reddened  and  turgid  from  the 
hyperaemia  induced  in  it  by  the  development  of  the  vesicle,  just  as  the  gum 
of  a young  child,  over  a large  jaw  tooth,  is  found  to  be  reddened  and  en- 
gorged from  a hypersemic  irritation,  arising  from  the  pressure  of  the  still 
uncut  tooth. 

Different  observers  report,  that  they  have  found  the  ovary  of  the  same 
side,  the  Fallopian  tube,  and  the  uterus,  of  a bright  red  colour  in  patients 
dying  suddenly  during  their  menstruation,  and  they  declare  it  to  be  an  inva- 
riable rule  to  find  the  evidences  of  a recent  rupture  in  all  such  persons, 
while  the  numerous  pits,  depressions  and  cicatriculae  to  be  noticed  upon 
the  surface  of  every  ovary  of  females,  between  fifteen  and  forty-five  years 
of  age,  are  regarded  as  the  vestigia  of  these  periodical  stated  developments 
and  burstings  of  the  Graafian  vesicle,  while  in  every  case  of  the  pregnant 
female,  or  the  gravid  mammal,  examined  after  death,  the  cicatricula  of  the 
ruptured  Graafian  vesicle  may  be  confidently  looked  for  on  one  or  the 
other  of  the  two  ovaries.  So  firmly  does  Mr.  Raeiborski  seem  to  regard 
this  doctrine  as  established,  that  he  calls  it  a regular  ponte  or  laying  pro- 
cess., whose  appearances  and  laws,  as  far  as  ascertained,  he  has  published  in 
his  recent  work,  Be  la  Puberte , fyc.  #*c. 

It  is  not  necessary,  nor  proper  for  me  in  this  place,  to  enter  fully  upon 
the  discussion  of  the  doctrine  set  forth  on  this  matter  by  M.  Negrier,  in  his 
work;  nor  of  M.  Gendrin,  in  his  Philos.  Pract.;  nor  of  Dr.  Lee,  in  his 
midwifery;  nor  of  M.  Raeiborski  in  his  volume;  I must  be  content  merely 
to  indicate  those  works  and  recommend  them  very  warmly  to  the  reader. 
In  those  works  he  will  find  that  the  ridiculous  notions  on  local  plethora 
without  cause — on  general  plethora  without  cause,  and  on  lunar  influence, 
as  the  proximate  cause  of  the  strange  and  hitherto  mysterious  phenomena, 
are  all  exploded,  and  that,  inasmuch  as  the  ovaries,  by  their  constitution,  are 
liable  to  the  hyperaemic  affluxion,  as  coincident  with  the  stated,  periodical, 
monthly  completion  of  a Graafian  vesicle,  which  hyperaemia  relieves  itself 
by  the  menstrual  discharge,  we  possess  in  that  law  the  key  to  all  the  de- 
rangements of  the  catamenial  office,  not  dependent  upon  some  obturation, 


462 


DISORDERS  OF  THE  MENSTRUATION,  ETC. 


or  some  sudden  shock  and  diversion  of  the  nervous  power  to  other  di- 
rections ; in  short,  we  have  the  means  in  our  hands  of  explaining  the  non- 
appearance  of  the  menses  at  the  age  proper  for  their  eruption — their  post- 
ponement or  anticipation  in  different  women,  and  their  protracted  duration 
in  some  women,  even  to  fifty  or  sixty  years,  or  more.  The  change  of  life, 
occurring  at  thirty  or  thirty-five  years,  instead  of  the  legitimate  time  of  forty- 
five  years,  is  also  explained.  This  doctrine,  too,  teaches  us  the  importance 
of  so  providing  for  the  health  of  young  girls,  as  to  enable  them  to  come  up 
to  the  puberic  age,  in  a condition  fitting  them  to  assume  this  great  office  and 
its  after  responsibilities,  while  it  directs  our  therapeutical  intervention  into 
the  only  true  path,  that  of  the  physiological  functions.  It  is  to  be  believed, 
that  if  menstruation  is  caused  by  the  regular,  periodical,  stated  production 
and  rupture  of  a Graafian  vesicle,  the  means  of  treating  the  disorders  of  men- 
struation must  be  such  as  are  directed  to  the  promotion  of  such  vesicular 
development,  called  by  Negrier,  le  travail  vesiculaire,  and  travail  ovarique. 

There  is  reason  to  believe  that  in  all  the  mammalia,  birds,  fishes,  insects, 
and  probably  in  all  the  vegetable  tribes,  the  development  of  germs  is  a 
stated  periodical  operation  ; and  there  is  little  difficulty  in  conceiving  that 
this  may  be  the  case,  if  we  reflect  upon  the  numerous  instances  of  periodi- 
city, observed  in  all  the  varied  functions  of  life. 

Having  premised  these  remarks,  in  which  I re-state  some  of  the  points 
set  forth  at  p.  25, 1 leave  to  the  reader  to  appreciate  M.  Colombat’s  opinions 
on  the  menstrual  affections,  here  following. — M.] 

Menstruation,  in  order  to  be  truly  effectuated,  requires,  like  most 
of  the  secretory  functions,  two  principal  and  distinct  actions,  which 
are  the  exhalation  of  the  menstrual  fluid,  and  its  excretion  to  the 
exterior.  When  one  or  the  other  of  these  actions  cannot  occur,  or 
is  but  imperfectly  accomplished,  there  result  absence,  suppression, 
diminution,  or  deviation  of  the  menstruae,  and  all  the  modifications 
of  menstruation,  which  can  be  comprised  in  two  principal  classes, 
which  are,  amenorrhoea , or  failure  of  the  menstrual  discharge,  and 
hypermenorrhoea , or  excess  of  the  same  discharge. 

These  two  principal  heads,  of  all  the  lesions  of  menstruation,  pre- 
sent divisions  which  may  be  distinguished  in  the  following  manner  : 

The  first  class  comprehends:  1,  menaphania  * or  non-appearance 
of  the  first  menstruae  ; 2,  dysmenophania ,t  or  difficult  establishment 
of  the  first  menstruation  ; 3,  me?iostasis,%  or  amenorrhoea  from  re- 
tention ; 4,  amenorrhoea,  properly  so  called,  or  suppression  of  the 
menstruae ; 5,  dysmenorrhcea,  or  incomplete  and  painful  discharge 
of  the  menstrual  fluid ; 6,  menometastasis ,§  or  deviation  of  the  men- 
struae ; 7,  menopausis, ||  or  the  cessation  of  the  discharge  at  the  criti- 
cal period. 

* From  the  Greek  /utht,  junvoj,  month;  a privative , and  <pavtia,  appearance , 
from  <pa  t>a  , 1 appear. 

f From  t u;,  with  difficulty ; month;  and  faveta,  appearance. 

± From  fxryo;  and  e-ram,  stagnation , retention. 

t)  From  fxtivo <■  and  /unrae-ram.  displacement. 

|j  From  fxry o{  and  naum,  cessation. 


AMESTORRHCEA. 


463 


The  second  class,  or  hypermenorrhoea , includes  menorrhagia  and 
the  different  sanguine  discharges  from  the  uterus. 

The  menstrual  disorders  that  we  have  now  enumerated,  instead  of 
forming  diseases  always  distinct,  are  commonly,  like  other  functional 
disturbances,  nothing  more  than  symptoms,  or  groups  of  symptoms 
resulting  from  a crowd  of  latent  affections,  from  different  sympathetic 
reactions,  or  from  some  organic  alteration  which  is  almost  always 
discoverable  by  an  attentive  examination. 

Though  the  more  or  less  complete  absence  or  suppression  of  the 
menstrucB,  present  very  evident  differences  in  relation  to  the  etiology, 
prognosis  and  treatment  of  such  disorders,  we  deem  it  right  to  study 
these  various  derangements  of  menstruation  collectively,  and  to  com- 
prise them  under  the  general  term  of  amenorrhoea , reserving  to  our- 
selves, however,  the  power  of  separating  them  in  the  research  after  the 
causes  which  give  rise  to  them,  and  in  the  curative  indications  which 
suit  each  more  particularly.  In  this  way,  we  shall  avoid  the  repeti- 
tions and  long  details  arising  from  divisions  unnecessarily  multiplied. 

OF  AMENORRHCE  A. 

Amenorrhoea,  which,  in  its  widest  acceptation,  embraces  all  cases 
in  which  there  is  failure  in  the  menstruse,  ought  to  be  divided  into 
primitive  and  consecutive.  Primitive  amenorrhoea,  comprising  the 
non-appearance  of  the  function,  at  the  epoch  of  puberty,  and  conse- 
cutive amenorrhoea,  which  means  their  accidental  and  more  or  less 
complete  suppression  after  menstruation  has  been  already  established, 
may  depend  upon  a general  condition  of  the  constitution,  upon  a phy- 
sical or  vital  lesion  of  the  uterus,  and,  lastly,  upon  the  sympathetic 
reaction  of  some  of  the  viscera  contained  in  the  splanchnic  cavities. 
By  founding  on  these  three  principal  origins  of  menstrual  derange- 
ments, we  have  constitutional  amenorrhoea , sympathetic  amenor- 
rhoea, and  amenor'rhcea  from  a local  cause. 

The  causes  of  primitive  constitutional  amenorrhoea  are  predisponent 
and  occasional.  Among  the  former  are  included,  1,  the  sanguine  tem- 
perament, which  is  manifested  by  a plethoric  condition  and  by  exces- 
sive fulness  of  the  vessels,  determining  local  congestions  in  different 
organs,  and,  in  that  way,  promoting  the  suppression  or  diminution 
of  that  of  which  the  uterus  ought  to  be  the  seat ; 2,  the  lymphatic 
temperament,  characterized  by  a condition  of  general  debility  and 
by  a want  of  activity  in  the  circulatory  system,  ought  likewise  to 
be  ranked  amongst  the  predisponent  causes  of  both  primitive  and 
consecutive  amenorrhoea.  Indeed,  do  we  not  daily  see  that  girls 
of  a lymphatic  constitution,  especially  those  exhibiting  symptoms  of 
scrofulous  disease,  are  regulated  later,  and  with  more  difficulty,  than 
others?  Is  it  not  known,  also,  that  women  already  regulated,  who 
are  placed  in  similar  conditions,  find  their  menstrual  discharges  dimi- 
nishing little  by  little,  or  becoming  entirely  suppressed ; the  periods 
of  return  becoming  more  and  more  distant ; the  retardations  con- 
stantly more  prolonged,  until  at  last  a complete  amenorrhoea  is  esta- 
blished ? 


464 


AMENORRHOEA. 


The  general  debility  which  is  so  often  the  cause  and  the  attendant 
of  amenorrhoea,  does  not  always  derive  its  origin  in  the  primitive 
constitution  of  the  female ; it  is  often  the  unfortunate  consequence 
of  a number  of  debilitating  causes,  such  as  living  in  a low,  humid 
situation,  deprived  of  the  light  of  the  sun  ; aliment  of  a bad  quality  ; 
warm,  watery  drinks;  insufficient  nourishment;  want  of  exercise,  or 
the  fatigue  produced  by  labour  beyond  the  strength  ; tedious  diseases 
and  convalescence ; the  abuse  of  sanguine  evacuations ; habitual 
leucdrrhcea,*  disappointment,  and  all  the  depressing  passions,  and, 
finally,  all  the  causes  which  impoverish  the  blood  and  render  it  inca- 
pable of  imparting  to  the  organs  the  energy  indispensable  for  the  full 
exercise  of  the  functions.  If  the  contrary  excess,  that  is  to  say,  the 
state  of  plethora,  produces  an  analogous  effect,  it  is  because  the  blood, 
too  rich  in  fibrine,  forms  an  obstacle  to  itself  and  itself  opposes  the 
periodical  exhalation  which  constitutes  menstruation. 

We  agree  with  MM.  Roche  and  Sanson, t Desormeaux  and  Paul 
Dubois, % Louis  Delaberge  and  Monneret,§  that  too  great  an  in- 
fluence has  been  falsely  attributed  to  the  nervous  temperament  in  the 
development  of  amenorrhoea.  Indeed,  observation  proves  that  women 
in  whom  the  nervous  temperament  predominates,  are  regulated  both 
sooner  and  more  copiously  than  others;  and  that  all  the  causes  which 
exalt  this  temperament,  such  as  powerful  passions,  the  culture  of  the 
arts,  erotic  studies,  precocious  or  too  often  repeated  enjoyments,  and, 
finally,  excitants  of  all  kinds,  far  from  causing  suppression  of  the 
menstruse,  do  but  precipitate  the  age  of  puberty  and  increase  the 
menstruation.  Besides,  is  it  not  known,  as  remarked  in  their  excel- 
lent compendium , (loc.  cit.)  by  MM.  L.  Delaberge  and  Monneret,  that 
in  warm  climates,  where  women  are  commonly  endowed  with  a ner- 
vous constitution  carried  to  its  maximum,  menstruation  is  very  early, 
very  active,  and  rarely  deranged  ? Beyond  a doubt,  the  nervous 
temperament  was  to  be  looked  upon  as  a predisposing  cause  of  the 
affection  which  engages  us,  because  it  is  not  uncommon  in  hysterical 
and  epileptic  women,  etc.;  this  error  would  certainly  have  been 
avoided,  and  the  effects  of  amenorrhoea  would  not  have  been  mis- 
taken for  the  cause  of  this  morbid  phenomenon,  if  it  had  been  re- 
marked that  the  menstrual  flux  may  be  suspended  by  all  sorts  of 
chronic,  inflammatory  and  nervous  affections,  and  that  very  often,  a 
crowd  of  neuroses  and  neuralgias  show  themselves  for  the  first  time, 
only  when  the  menstrum  are  suppressed.  Finally,  chlorosis  and 
anemia  have  been  properly  ranked  amongst  the  predisponent  causes 
of  constitutional  amenorrhoea. 

The  exciting  causes  of  constitutional  amenorrhoea,  are  no  other 

* Our  young  fellow-practitioner  and  friend,  Dr.  Marc  d’Espine,  of  Geneva,  says, 
in  a memoir  inserted  in  the  Archives  generates  de  medecine,  for  the  year  1835,  that  of 
eighty  women  observed  at  Paris,  twenty-seven  only  had  never  had  fluor-albus;  he 
adds  that  of  the  fifty-three  others,  twenty-six  had  it  before  puberty,  eighteen  during  that 
epoch,  and  nine  only  after  that  physiological  revolution. 

fNouveaux  elements  de  pathologie,  t.  ii.  p.  492. 

j Diet,  de  Medecine,  t.  ii.  part,  amenorrhee,  2d  ed. 

§ Compendium  de  Med.  Prat.,  t.  i.  p.  57,  1836. 


AMENORRHCEA. 


465 


than  the  predisposing  causes  we  have  just  enumerated,  and  which, 
from  having  lasted  longer,  or  having  progressively  reached  a higher 
degree  of  intensity,  may  produce  a more  or  less  complete  amenor- 
rhoea,  which  then  constitutes  a case  most  obstinate,  most  rebellious, 
and  most  fruitful  in  accidents. 

The  causes  both  of  primitive  and  consecutive  sympathetic  amenor- 
rhoea, ought  to  be  referred  to  three  principal  heads,  to  wit:  the  moral , 
physical  and  symptomatic  causes  of  some  visceral  disorder,  or  one 
dependent  upon  an  acute  irritation  of  any  part  of  the  economy. 

Amongst  the  moral  causes , should  be  ranked  the  vivid  emotions 
of  the  soul,  as  anger,  disappointed  love,  celibacy,  despair,  jealousy, 
immoderate  joy,  profound  depression,  the  sudden  reception  of  bad 
news,  a sudden  fright,*  extreme  fear,  or  a sudden  disappointment. 
A tuberculous  female  in  the  wards  of  M.  Rostan,  had  her  monthlies 
suddenly  suppressed  on  learning  that  the  application  of  a seton  to 
the  parietes  of  the  thorax  had  been  prescribed  for  her.t  We  might 
cite  a large  number  of  cases  of  the  same  kind,  of  the  sympathetic 
influence  of  the  nervous  system  and  of  the  brain  in  particular,  were 
they  not  already  so  generally  acknowledged. 

The  physical  causes  that  may  still  more  suddenly  arrest  the 
menstrual  discharge,  are : sudden  exposure  to  cold  and  damp  air, 
the  immersion  of  the  feet  or  hands  in  cold  water,  cold  ablutions  of 
the  sexual  organs,  sitting  upon  the  grass,  on  the  ground,  or  on  a stone- 
bench;  the  ingestion  of  ices,  of  sherbets,  and  of/ very  cold  drinks,  and 
especially  when  taken  while  the  body  is  in  a statoof  perspiration; 
a violent  bleeding ; the  application  of  a large  blister,  of  cups,  etc.;  a 
wound,  a burn,  a hsemorrhage;  the  employment  of  purgatives,  of 
emetics,  or  of  cinchona  in  large  doses;  the  action  of  strong  odours, 
particularly,  according  to  Haller’s  assertion,  the  herb  penny-royal ; 
and,  finally,  all  circumstances  capable  of  suddenly  drawing  in  other 
directions  than  towards  the  uterus,  the  blood  which  ought  to  be 
exhaled  by  that  organ  at  this  period. 

Amongst  the  causes  of  sympathetic  amenorrhma,  we  should  also 
include  phthisis  pulmonalis,  hypertrophy  of  the  heart,  the  different 
dropsies,  scrofulous  and  tuberculous  affections,  softening  of  the  bones, 
the  acute  and  chronic  inflammations  of  the  skin,  of  the  stomach,  the 
pleurae,  the  lungs,  the  liver,  the  spleen,  the  peritoneum,  the  brain  and 
its  membranes,  the  spinal  marrow,  and  all  the  visceral  irritations 
which  retain  the  blood  and  prevent  it  from  being  directed  upon  the 
uterus.  Finally,  the  sudden  suppression  of  the  perspiration,  or  a 

*From  the  report  of  Baudelocque,  (loco  citato,)  sixty-two  women  were  attacked 
with  hsemorrhage  or  suppressions  upon  the  occasion  of  the  explosion  of  the  powder- 
magazine  of  Grenelle.  M.  Husson  has  also  collected  the  case  of  a woman  who,  at 
several  different  times,  was  attacked  with  menstrual  suppressions,  under  the  influ- 
ence of  claps  of  thunder.  We  ourselves  observed,  in  July,  1830,  that  the  reports 
arising  from  the  platoon  firing  and  cannon-shot,  produced  the  same  effect  in  several 
women,  amongst  others  in  a young  person  eighteen  years  old. 

-j-Some  months  since,  one  of  our  relations,  whose  menstruation  is  ordinarily  very 
regular  and  abundant,  was  attacked  with  a sudden  suppression,  in  consequence  of  a 
frightful  dream,  a kind  of  night-mare. 

30 


466 


AMENORRHOEA. 


considerable  augmentation  of  this  or  of  any  other  secretion,*  may 
also  determine  the  non-appearance,  the  suppression  or  diminution  of 
the  menstruae. 

The  causes  of  amenorrhoea  that  are  dependent  upon  a local 
condition  of  the  genital  organs , ought  likewise  to  be  referred  to 
three  principal  heads,  to  wit : vital  lesions,  lesions  of  situation,  and 
lesions  of  form  and  development  of  the  uterus  and  its  appendages. 

Amongst  the  causes  depending  upon  vital  lesions  of  the  sexual 
organs,  we  ought  to  mention  acute  and  chronic  inflammation,  indu- 
ration, the  different  engorgements,  ulceration,  excessive  sensibility, 
and  the  state  of  anemia  of  the  gestative  organ,  and  of  the  ovaries ; 
and,  finally,  the  presence  of  false  membranes;  physometra,  hydrome- 
tra,  and  uterine  hydatids,  also  produce  suppression  of  the  rnenstruae. 

The  causes  depending  on  lesions  of  situation  are,  anteversions, 
retroversions,  flexions  and  incomplete  prolapsus  of  the  womb. 
Though  these  different  displacements  do  not  prevent  the  exhalation  of 
the  menstrual  fluid,  they  often  constitute  temporary  obstacles  to  its  ex- 
cretion, because  the  os  tine®  being  strongly  pressed  against  the  sacrum 
or  pubis,  there  results  from  this  a more  or  less  complete  closure  of 
the  uterine  orifice.  Finally,  amongst  the  causes  depending  on  lesions 
of  form  and  of  development , we  range  the  absence,  atrophy,  and 
failure  of  development  of  the  uterus  and  ovaries,  of  which  we  have 
given  examples  at  pages  76,88  and  118;  imperforation  of  the  os 
tincse  and  of  the  hymen  ; obliteration  of  the  vagina  and  of  the 
mouth  of  the  uterus;  primitive  or  accidental  agglutination  of  the  labia 
majora,  and  of  the  walls  of  the  vagina  ; and,  lastly,  the  different 
kinds  of  atresia  of  the  sexual  cavities,  of  which  we  treated  at  pages 
74  and  119,  should,  likewise,  be  included  amongst  those  local  lesions, 
which  may  prevent  the  exhalation,  or  more  commonly  the  excretion 
of  the  menstruae.  We  add  that  it  is  often  impossible  to  discover  the 
cause  of  the  non-appearance,  or  of  the  consecutive  suppression  of  the 
menstruation. 

The  symptoms  of  amenorrhoea , which  vary  according  to  the 
causes  of  the  disease,  ought  to  be  divided  into  two  series.  To  the 
first  belong  the  local  symptoms,  such  as  pains  and  dragging  sensation 
in  the  lumbar  region,  and  a sense  of  weight  in  the  pelvis,  and  espe- 
cially behind  the  pubis.  Amenorrhoea,  owing  to  engorgement  of  the 
womb,  comes  on  with  a sensation  of  a somewhat  acute  local  sensi- 
bility, which  often  inclines  women  to  onanism,  and  especially  makes 
them  desire  coitus  even  when  it  is  tfery  painful  to  them.  If  the  non- 
appearance  of  the  menstruation  depends  upon  a congenital  fault  of 
conformation,  which,  moreover,  does  not  manifest  itself  until  the 
epoch  of  puberty,  the  menstrual  blood  is  accumulated  in  the  vagina 
or  in  the  uterus,  and  forms  above  the  obstacle  a tumour,  whose  most 
marked  character  is  that  of  increasing  periodically  each  month,  that 

* This  is  the  reason,  no  doubt,  that  professional  danseuses  are  usually  scarcely 
ever  well  regulated,  as  well  as  all  those  women,  who,  from  their  condition  of  life, 
give  themselves  up  to  fatiguing  labours,  which  provoke  in  them  abundant  and 
almost  constant  sweats.  Moreover,  is  it  not  known  that  lactation,  diabetes,  and  all 
the  dropsical  diseases  almost  invariably  lead  to.  suppression  of  the  menstruation? 


AMENORRHGEA. 


467 


is  to  say,  at  the  epochs  when  the  menstruse  ought  to  be  excreted, 
and  then  of  remaining  stationary  during  the  intervals  between  the 
sanguine  exhalations.  In  cases  where  the  retention  is  due  to  an  acci- 
dental imperforation  or  obliteration  of  the  mouth  of  the  uterus,  the 
tumour,  or  rather  the  distended  uterus  appears  first  on  a level  with 
the  pubis,  and  then  rising  gradually  from  the  hypogastrium  to  the 
umbilicus,  it  simulates  pregnancy  the  more  closely,  inasmuch  as  it 
exhibits  most  of  the  sympathetic  phenomena,  and  particularly  the 
swelling  of  the  mammae.  If  the  obstacle  is  situated  at  the  orifice  of 
the  vulva,  and  it  be,  for  example,  an  imperforate  hymen,  that  mem- 
brane, pressed  forwards  by  the  blood  accumulated  in  the  vagina, 
forms  between  the  labia  majora,  a hemispherical,  livid  or  bluish, 
soft  and  fluctuating  tumour,  becoming  more  prominent  when  the 
female  is  erect.  (See  our  remarks  upon  this  matter,  pp.  79  and  89.) 
In  most  cases,  the  exploration  of  the  genital  parts,  and  especially 
the  examination  per  vaginam,  per  rectum,  and  by  the  hypogastrium, 
suffice  to  reveal  the  nature  and  seat  of  the  obstacle,  and  to  establish 
a positive  diagnosis.  We  shall  add  that  the  pressure  of  the  tumour 
on  the  sciatic  nerves,  the  sacral  plexus,  the  rectum  and  the  bladder, 
often  determines  engorgement,  cramps  and  numbness  of  the  inferior 
extremities,  and  troublesome  weight  in  the  pelvis,  and  sometimes 
even  difficulty  and  frequency  in  the  expulsion  of  the  urine  and 
faecal  matters.  (For  fuller  details,  see  p.  89  et  seq.) 

Where  the  symptoms  we  have  just  pointed  out  appear  for  the  first 
time,  and  especially  where  they  are  not  followed  by  symptoms  too 
serious,  it  would  be  prudent  to  wait  for  another  menstrual  period  ; for 
it  frequently  happens  that  the  sanguine  exhalation  does  not  establish 
itself  completely,  or  fails  to  reappear  after  being  suppressed,  until  the 
second  or  third  term,  or  even  until  a more  distant  period ; neverthe- 
less, if  a real  condition  of  disease  should  result  from  the  amenorrhoea, 
it  would  be  important  to  convince  ourselves,  as  early  as  possible, 
whether  the  organs  of  generation  and  the  pelvic  cavity  are  properly 
developed,  and,  finally,  whether  the  enlargement  and  sensibility  of 
the  mammse,  as  well  as  all  the  local  symptoms  of  menstruation, 
appear  at  regular  epochs. 

The  general  symptoms  or  sympathetic  signs,  which  are  often 
the  only  ones  that  announce  primitive  menaphania , or  the  accidental 
suppression  of  the  monthlies,  vary  by  their  nature,  their  modifica- 
tions, their  obstinacy  and  their  termination,  according  to  a great 
number  of  individual  circumstances,  such  as  age,  temperament, 
ordinary  disposition,  education,  and  the  kind  of  life  more  or  less  con- 
trary to  the  laws  of  hygiene.  Thus,  the  young  woman,  heretofore 
brilliant  with  freshness,  strength  and  health,  suddenly  sees  her  fea- 
tures assume  the  impress  of  feebleness,  depression  and  languor ; the 
roses  upon  her  countenance  fade  ; the  fire  of  her  eyes  is  extinguished, 
and  a dark  areola  surrounds  them;  finally,  the  most  frequent  symp- 
toms are  habitual  cephalalgia,  dyspnosa,  dizziness,  oppression,  pains 
in  the  limbs,  especially  at  the  joints,  and  an  excessive  susceptibility, 
which  changes  her  character  and  renders  it  impatient  and  irascible. 


468 


AMENORRHCEA. 


The  moral  alteration  is  not  less  considerable  than  the  physical.* 
The  ideas  become  sad,  the  imagination  is  sombre;  sometimes,  the 
exaggerated  sensibility  causes  the  patient  to  seek  for  solitude,  and 
shed  causeless  tears;  sometimes,  on  the  contrary,  she  becomes  pas- 
sionately fond  of  music,  theatres  and  amusements  of  all  kinds. 

Though  there  be  a small  number  of  women,  never  having  been 
regulated,  who  seem  to  enjoy  moderately  good  health,  the  great 
majority  of  those  who  are  in  this  condition,  suffer  at  periodical 
epochs  from  most  of  the  symptoms  that  we  have  just  enumerated, 
and  then,  without  any  menstrual  discharge  making  its  appearance, 
calm  returns,  and  both  the  general  and  local  symptoms  are  partially 
dissipated,  until  another  epoch  arrives  which  occurs  every  month. 
Other  women  reach  a certain  age  without  suffering  any  periodical 
indispositions,  but  their  health  is  habitually  deranged ; they  are  subject 
to  leucorrhceal  discharges,  to  cholic,  to  diarrhoea,  palpitations,  and 
headaches ; their  tissues  are  soft,  flaccid  and  colourless,  and,  finally, 
every  thing  about  them  bears  the  marks  of  langour  and  suffering. 
They  are  fortunate,  if  to  all  these  general  symptoms  are  not  added 
cutaneous  affections,  vicarious  haemorrhages,  chlorosis,  infiltration  of 
the  cellular  tissue,  ascites,  and  a crowd  of  neuroses,  such  as  hysteria 
nymphomania,  epilepsy,  mania,  convulsions,  chorea  and  the  whole 
train  of  nervous  diseases. 

Women,  who  have  never  been  regulated,  and  who  enjoy,  never- 
theless, perfect  health,  are  generally  more  or  less  unendowed  with 
the  attributes  of  their  sex  ; in  them,  the  breasts,  the  womb,  and  the 
ovaries,  are  scarcely  developed,  and  may  be  entirely  absent.  Their 
physical  constitution,  as  well  as  their  moral  life,  approximates  to  that 
of  the  male,  whose  form,  strength,  courage,  taste,  inclinations,  pas- 
sions, etc.,  they  most  commonly  represent. t Baudelocque,  ( Art . des 
accouch.,  t.  i.,  p.  183,)  speaks  of  a woman  who  was  destitute  of  an 
uterus  ; she  loved  the  chase,  horses,  arms ; she  cultivated  belles-let- 
tres, and  had  never  felt  any  thing  which  revealed  a retention  of  the 
menstrual  blood,  nor  even  the  want  of  this  evacuation.  She  was 
married,  and  fulfilled,  but  very  imperfectly,  the  duties  of  a wife,  and 
without  caring  for  its  sweets. 

Amenorrhoea  depending  upon  disease  of  some  viscus,  may  appear 
at  the  commencement  of  such  disease,  or  at  a rather  advanced  period 
of  it ; and,  though  it  is  impossible  to  statue  any  thing  positively  upon 
this  point,  we  may  say,  generally,  that  the  menstrual  derangement 
declares  itself  the  sooner  in  proportion  to  the  degree  of  sympathy 
between  the  disordered  organs  and  the  uterus ; for  example,  when  the 

* According  to  M.  Broussais,  (Cours  de  Palhologie,  tom.  ii.  p 230,)  this  is  ex- 
plained anatomically  by  the  intimate  relations  of  the  uterus  with  the  spinal  marrow, 
and  consequently  with  the  portions  of  the  brain  devoted  to  the  affective  passions;  as 
has  been  demonstrated  by  M.  Ollivier  d’ Angers,  in  his  treatise  on  diseases  of  the  me- 
dulla spinalis. 

f Might  we  not  ask,  whether  those  heroines,  whose  lofty  deeds  vve  admire  in  his- 
tory, and  who  differed  so  wonderfully  from  other  persons  of  their  own  sex,  whether 
those  heroines,  we  repeat,  who  lived  only  in  combats  and  camps,  were  not  deprived 
of  uterus  and  ovaries,  or  whether,  at  least,  those  organs  had  not  remained  in  the 
inertia  in  which  they  are  naturally  plunged  during  the  early  years  of  life? 


AMEN0RJRHG2A. 


469 


stomach,  the  brain,  or  the  heart,  is  affected,  the  amenorrhoea  comes 
on  at  a very  early  period,  whilst  in  phthisis  pulmonalis,  the  complete 
suspension  of  the  menstruse  does  not  occur  until  the  stage  when  the 
tubercles  begin  to  soften.  We  may  state,  furthermore,  that  the  ple- 
thoric and  nervous  constitutions  exert  a marked  influence  upon  the 
symptomatic  or  sympathetic  suppressions  of  menstruation,  which 
often  coincide  in  persons  who  present  the  individual  conditions  we 
have  just  mentioned,  with  inflammation  of  a viscus  or  some  mem- 
branous organ. 

Before  concluding  what  we  have  to  say  upon  the  symptoms  of 
amenorrhoea,  we  shall  state,  that  when  accidental,  and  especially 
where  the  suppression  has  been  sudden,  the  woman  immediately  feels 
a sensation  of  heat,  weight  and  pain  in  the  pelvis;  more  or  less  violent 
uterine  colic,  and  a disagreeable  tension  in  the  inguinal  and  lumbar 
regions,  and  the  upper  part  of  the  thighs  ; finally,  there  are  added 
to  these  symptoms,  enlargement  of  the  abdomen  and  mammae ; an 
indescribable  feeling  of  malaise  and  lassitude  ; extreme  loathing, 
nausea,  vomiting,  headache,  vertigo,  tinnitus  aurium,  oppression,  fre- 
quent palpitations,  and,  in  many,  a burning  pain,  during  the  expulsion 
of  urine.  Independently  of  all  these  symptoms,  which  are  peculiar 
almost  to  the  sanguine  temperament,  we  often  see  arise,  when  the 
suppression  is  of  no  recent  date,  chronic  affections,  such  as  chloro- 
sis, leucorrhoea,  metritis,  engorgements,  scirrhus,  and  cancer  of  the 
uterus.  We  call  attention,  also,  to  the  fact,  that  amenorrhoea  symp- 
tomatic of  some  other  disease,  especially  that  which  has  come  on 
slowly  and  progressively,  sometimes  aggravates  the  disease  upon 
which  it  depends,  whilst,  under  other  circumstances,  it  is  favourable 
to  it.  It  is  useless  to  say,  that  in  the  former  case  it  ought  to  be 
treated,  while  in  the  latter  we  should  let  it  alone. 

Among  the  most  curious  phenomena  following  suppression  of  the 
menses, should  be  ranked  the  haemorrhages  and  other  vicarious  evacua- 
tions, of  which  a more  singular  example  cannot  be  found  than  that  re- 
lated by  Gardien,  ( Trciitk  d’JJccoitch.,  t.  i.,)  and  observed  at  the  hos- 
pital La  Salpetriere,in  a girl  who,  after  suppression  of  the  menses,  had  a 
periodical  sanguine  discharge  : 1,  during  six  months,  from  small  ulcers 
in  the  legs  ; 2,  for  a year,  from  ulcers  on  the  arms ; 3,  for  six  months, 
from  the  opening  of  a paronychia  of  the  left  thumb ; 4,  for  two  years, 
from  ulcers  at  the  angle  of  the  eye,  consequences  of  an  erysipelas  of 
the  face ; 5,  for  five  months,  from  the  umbilicus  where  another  erysi- 
pelas had  made  its  appearance  ; 6,  for  four  months,  from  the  internal 
malleolus  of  the  left  foot ; 7,  and  finally,  for  two  months,  from  the 
left  ear.  When  the  blood  ceased  to  flow  from  a fixed  point,  there 
occurred  attacks  of  epistaxis  and  haemoptysis,  preceded  by  convul- 
sions, headaches,  and  dizziness.  Doctor  Chatelain,  of  Nancy,  in  his 
thesis,  ( Essai  sur  la  mensh'uation,  1827,)  speaks  of  a prostitute 
seen  by  M.  Bonfils,  at  the  Magdalen  Society  of  that  city,  who, 
in  consequence  of  derangement  of  menstruation,  had  sanguine  dis- 
charges successively  from  the  arm-pit,  the  nipple,  the  left  flank,  the 
back,  the  epigastrium,  and  the  thigh.  M.  Chatelain,  likewise,  cites 
a case  observed  by  M.  Begin,  concerning  a young  person,  whose 


470 


AMENORRHOEA. 


left  index-finger,  in  consequence  of  amenorrhoea,  swelled,  and  was 
covered  by  an  acute  herpetic  eruption  from  the  surface  of  which 
flowed  several  drops  of  blood,  at  a certain  period  of  every  month. 
The  herpes  and  the  discharge,  which  lasted  only  three  or  four  days, 
were  accompanied  by  a disagreeable  pruritus.  It  was  not  until  three 
years  later  that  the  womb  returned  to  its  regular  functions,  and  the 
health  of  the  patient  was  completely  re-established. 

The  point  at  which  the  vicarious  hsemorrhage  takes  place,  gene- 
rally varies  according  to  the  age  of  the  female ; during  youth,  it  is  from 
the  nose  and  chest ; later  in  life,  from  the  haemorrhoidal  vessels,  the 
stomach  and  the  bladder.  According  to  Stahl,  ( de  mensium  insolit. 
viis,)  an  indigestion  or  a pulmonary  catarrh  occurring  during  men- 
struation, suffices  to  provoke  the  afflux  of  blood  towards  these  diges- 
tive and  respiratory  organs.  Yet,  though  epistaxis,  haematemesis, 
haemoptysis  and  haematuria,  may  be  the  most  frequent  of  these 
haemorrhages,  we  could  cite  other  examples  of  these  menstrual  de- 
viations taking  place  from  other  fixed  points  of  the  economy.  Bau- 
douin  Ronssaeus  ( OpuscuL  med.  de  morb.  mitlier.,)  states  that  a 
woman  having  had  a molar  tooth  extracted,  had  a suppression,  and 
that  a discharge  of  blood,  which  was  renewed  every  month,  was  esta- 
blished from  the  alveolus  of  this  tooth.  Raymond  speaks  of  an  un- 
married woman  who,  at  the  age  of  forty-eight,  had  a slight  haemor- 
rhage once  a month  from  the  alveolus  of  a tooth  which  she  had  lost. 
The  same  author  adds,  that  the  discharge  of  blood,  which  lasted 
three  days,  was  about  three  ounces  per  diem.  J.  N.  Pechlin,  ( Ob - 
serv.  physic,  med.,  lib.  iii.,)  relates  a case  of  menstrual  haemorrhage, 
which  took  place  from  an  ulcer  on  the  foot.  Theod.  Kerckring, 
( Spiceleginni  anat.  cont.  observ.  cinat.  rar.,)  cites  the  case  of  a girl 
who  was  periodically  regulated  from  a wound  in  the  right  hand. 
Louis  Mercatus,  [de  morb.  mulier.  lib.  iv.,)  mentions  a woman  that 
was  not  regulated,  whose  cheeks  became  of  a very  deep  red  colour 
every  month.  Finally,  to  the  long  enumeration  of  menstrual  irre- 
gularities, reported  by  Haller,  [Element,  physiol,  corp.  human.,) 
Freind,  [Emmenol,  cap.  viii.,)  and  Royer  Collard,  [Essaisur  Vame- 
norrhee,  p.  28,)  we  will  add  that  Baudelocque,  ( Traitb  des  accouch .) 
who  was  acquainted  with  a woman  forty-five  years  old,  who  had  never 
been  regulated,  and  who  was  subject,  during  three  days  of  every 
month,  to  a diarrhoea.  M.  Brera,  ( Essai  clinique  sur  Viode ,)  mentions 
a woman  who,  in  consequence  of  a menstrual  suppression,  was  sub- 
ject every  month,  for  two  years,  to  a dysenteric  flux,  which  lasted 
five  or  six  days  ; we  will  add,  also,  that  we  saw  a similar  case  in  a 
female,  who  was  in  the  wards  of  Fouquier,  in  1830. 

The  diagnosis  of  amenorrhoea  is  not  always  easy  to  establish. 
Therefore,  we  think  that  a physician,  in  such  cases,  should  use  the 
greatest  reserve,  and  behave  with  the  utmost  prudence  and  circum- 
spection, in  order  to  avoid  mistakes,  and  especially  the  snares  which 
might  be  tendered  him.  In  effect,  may  it  not  happen  that  young 
girls  and  widows,  interested  to  conceal  their  pregnancy,  shall  seek, 
with  criminal  intentions,  to  deceive  their  physician  as  to  their  real 
condition,  in  the  hope  that  the  remedies,  and  especially  the  bleedings 


AMENORRH(EA. 


471 


which  might  be  ordered  for  suppression  of  the  menses,  shall  lead  to 
the  criminal  end  they  seek  to  attain.  Besides,  may  not  women,  in- 
voluntarily, deceive  themselves  as  to  their  condition  of  pregnancy, 
and  suppose  that  they  merely  labour  under  a suppression  attribu- 
table to  some  accidental  cause.  Is  it  not,  also,  true,  that  women, 
aware  of  the  arrival  of  the  critical  age,  by  the  cessation  of  the  men- 
strual discharge,  seek,  by  remedies  not  always  unattended  with 
danger,  to  prolong  the  marks  of  a youthfulness  which  has  passed 
away,  by  recalling  the  signs  of  a fecundity  which  no  longer  exist  ? 
To  administer  remedies  in  such  cases  without  any  precaution,  would 
be  to  expose  ourselves  on  the  one  hand  to  the  danger  of  inducing 
abortion,  and  on  the  other  of  determining  dangerous  haemorrhages 
and  inflammations,  which  may  be  followed  by  the  most  serious 
consequences.  To  avoid  unhappy  mistakes,  and  the  snares  held  out 
by  the  fear  of  dishonour  and  the  desire  of  concealing  the  ravages 
of  years,  the  physician  who  feels  any  uncertainty,  should  endeavour 
to  temporize,  as  much  as  possible,  until  he  can  discover  the  true 
cause  of  the  suppression,  and  confine  himself  to  a grave  prescription 
of  insignificant  remedies,  especially  in  cases  where  the  health  no 
longer  requires  any  therapeutical  intervention.  This  conduct  seems 
the  more  rational,  as  there  are  no  positive  signs  of  commencing 
pregnancy,  and  as,  after  the  fifth  month,  ballottement,  the  sponta- 
neous movements  of  the  foetus,  and  the  use  of  the  stethoscope,  permit 
us  no  longer  to  doubt  on  this  point. 

Supposing,  that  by  a series  of  questions  adroitly  asked,  we  have 
succeeded  in  convincing  ourselves  of  the  good  faith  of  the  patient, 
who  might  be,  moreover,  by  her  social  position  and  known  morality, 
above  all  suspicion,  the  first  thing  to  seek  after,  would  be  to  dis- 
cover whether  the  uterus  were  primarily  or  sympathetically  affected. 
By  the  exploration  of  the  sexual  organs,  we  could  always  recognize 
the  local  lesions  that  might  give  rise  to  amenorrhoea  depending  on 
this  cause ; we  ought  particularly  to  insist  upon  this  means  of  diag- 
nosis before  commencing  any  treatment,  provided  the  suppression, 
already  of  longstanding,  have  resisted  the  ordinary  remedies.  Never- 
theless, we  ought,  as  M.  Lisfranc*  directs,  to  be  careful  in  the  case 
of  the  virgin  young  girl,  and  rest  contented  with  examining  merely 
by  the  rectum,  the  vagina,  and  the  uterus. 

Should  the  amenorrhoea  co-exist  with  any  lesion  whatsoever  of 
some  other  organ,  we  should  try  to  discover  whether  that  organ  is 
affected  primarily  and  reacts  sympathetically  on  the  uterus,  or  whe- 
ther, on  the  contrary,  it  is  a morbid  condition  of  this  latter  viscus 
that  reflects  its  unhealthy  influence  on  a part*  or  the  whole  of  the 
economy.  The  origin  of  the  disease  may  generally  be  detected  by 
carefully  studying  the  temperament  and  constitution  of  the  woman, 
as  well  as  the  modifications  and  sequence  of  the  symptoms.  We 
must  acknowledge,  however,  that  there  are  some  very  embarrassing 
cases,  in  which  we  can  discover  neither  any  lesion  nor  any  cause  to 
clear  up  the  diagnosis. 

* Bulletin  clinique,  par  MM.  Piorry,  Rameaux,  L’hSritier,  Thibert,  No.  5,  1 Sep- 
ember,  1835,  and  compendium  de  med.  pratiq.  de  MM.  Delaberge  et  Monneret,  t.  i, 
p.  62,  1836. 


472 


AMENORRHOEA. 


The  prognosis  of  amenorrhoea  must  necessarily  vary  according  to 
the  causes  which  have  produced  it,  according  to  its  duration  and  the 
severity  of  the  accompanying  symptoms.  Amenorrhoea  connected 
with  a plethoric  constitution  is  not  always  complicated  with  serious 
symptoms ; often,  indeed,  is  it  accompanied  by  mild  ones,  which  are 
usually  readily  controlled  ; nevertheless,  a strongly  marked  plethoric 
condition  may  give  birth  to  acute  inflammations,  which  sometimes 
resist  the  most  energetic  treatment,  but  which  always  cease  updn  the 
appearance  of  the  menses.  When  the  non-appearance  or  suppres- 
sion of  the  menses  is  the  result  of  constitutional  debility,  the  progress 
of  the  disease  is  slow,  and  it  assumes  a character  of  languor  and 
inertia,  which  forms  an  obstacle  to  the  cure,  which  is  always  obtained 
with  greater  difficulty  than  when  the  disease  depends  upon  a gene- 
rally plethoric  condition.  Amenorrhoea,  in  the  year  following  the 
first  menstrual  irruption,  at  the  age  of  puberty,  is  not  of  much  conse- 
quence, and  is  scarcely  ever  due  to  a seriously  morbid  state  of  the 
uterus.  That  which  attacks  suddenly,  occasions  inflammatory  symp- 
toms, which,  for  the  most  part,  are  readily  controlled  as  no  doubt 
rests  upon  the  diagnosis.  It  even  happens,  sometimes,  that  the 
menses  appear  at  the  next  epoch,  and  that  this  indisposition,  which 
women  call  retard , yields  to  simple  remedies  or  to  the  powers  of 
nature  alone.  In  these  cases  menstruation  often  returns  with  such 
violence  as  to  constitute  a real  haemorrhage. 

The  prognosis  of  amenorrhoea  from  a local  disease,  must  always 
depend  upon  the  nature  of  the  lesion  which  has  produced  it.  It  is 
most  troublesome,  generally,  when  the  menstrual  suppression  depends 
upon  a simple  chronic  engorgement,  or  upon  chronic  induration  o 
the  neck  or  body  of  the  gestative  organ.  If  sanguine  congestion  has 
induced  the  amenorrhoea,  and  the  physician  recognizes  the  nature 
of  the  disease,  it  is  very  rare  for  him  to  be  unable  to  apply  a prompt 
remedy,  unless,  indeed,  the  engorgement  be  the  first  stage  of  some 
degeneration  of  the  uterus. 

It  becomes  necessary  to  pay  the  strictest  attention  to  the  case, 
where  the  suppression  is  of  long  standing,  even  though  the  patient 
has  not  suffered  from  any  serious  disorder.  Although  it  is  very  difficult 
to  ascertain  what  organ  was  primarily  affected  in  such  a case,  and, 
consequently,  to  establish  the  basis  of  a rational  treatment,  that  end 
may  often  be  attained  by  studying  all  the  commemorative  symptoms, 
and  carefully  comparing  them  with  those  that  actually  exist.  The 
older  the  amenorrhoea,  the  more  difficult  is  it  to  overcome  it  by 
therapeutical  agents  : one  that  has  lasted  for  several  years,  offers 
but  slight  chances  of  cure  ; and  it  is  well  known  that  the  father  of 
Medicine  gave  a still  more  unfavourable  prognosis,  which,  however, 
is  not  supported  by  experience,  when  he  said,  ( De  rnorb.  rnulier.): 
“ Sexto  mense  insanubilis  ?norbus  redditur , qui  antea  curari  pro - 
ter  at”  Women  have  been  known  to  become  habituated  sometimes 
to  the  loss  of  the  menstrual  discharge,  and  to  suffer  no  consequent 
inconvenience.  In  cases  of  that  kind,  we  ought  not  to  fatigue  the 
patient  by  useless  treatment,  but  be  contented  with  preventing  and 
combating  any  symptoms  which  may  arise.  In  certain  cases,  where 


AMENORRHCEA. 


473 


the  most  rational  treatment  has  failed,  the  return  of  the  menses  has 
followed  pregnancy.  As  to  the  prognosis  to  be  made  in  amenorrhcea 
depending  on  disease  of  some  important  viscus,  we  shall  rest  satisfied 
with  saying,  that  it  is  altogether  subordinate  to  the  nature  of  the  dis- 
ease ; if  the  suppression  be  connected  with  phthisis  pulmonalis,  or 
any  other  profound  disorganization,  the  chances  of  recovery  are  the 
same  as  those  of  the  primary  diseases.  As  we  should  be  compelled, 
in  order  to  offer  any  positive  statements  on  this  point,  to  pass  in 
review  the  whole  nosological  catalogue,  we  shall  be  content  with 
stating  that  the  prognosis  varies  according  to  the  importance  of  the 
organ  primarily  or  secondarily  affected,  and  according  to  the  more  or 
less  favourable  general  circumstances  in  which  the  patient  may  be 
placed. 

The  prognosis  of  amenorrhea  from  non-excretion  is  not  generally 
unfavourable,  because  both  the  vicious  disposition  and  the  obstacle 
which  prevent  the  escape  of  the  menstruae  may  commonly  be  cor- 
rected. The  cure,  however,  is  difficult  to  obtain  where  the  occlusion 
is  deeply  situated,  and  especially  when  it  depends  on  a more  or  less 
extensive  adhesion  of  the  walls  of  the  vagina  or  uterus.  Rupture 
of  the  Fallopian  tubes  has  been  proved  to  occur  in  cases  of  this  kind 
from  the  accumulation  of  blood  : it  is  useless  to  add  that  the  effusion 
of  the  fluid  into  the  abdomen  has  always  produced,  as  its  inevitable 
and  almost  immediate  cause,  the  death  of  the  patient.  In  fine,  we 
conclude  by  saying  that  we  should  never  interfere  with  the  vicarious 
haemorrhages  and  other  discharges,  which,  to  a certain  extent,  are 
the  substitutes  of  the  menses,  and  that  we  cannot,  be  too  watchful 
of  the  function  in  a delicate  girl,  whose  limbs  are  slight,  whose  chest 
is  contracted,  and  whose  constitution  is  predisposed  to  tuberculous 
affections. 

The  treatment  of  amenorrhoea  must  be  regulated  according  to  the 
physical  and  moral  circumstances  and  causes  which  have  brought 
on  or  that  keep  up  the  disease. 

When  the  amenorrhoea  is  simple,  and  occurs  in  a girl  of  a depraved 
constitution,  with  a predominance  of  the  lymphatic  system,  we  should 
direct  a prolonged  insolation,  a fresh  and  dry  air,  especially  in  a 
mountainous  country,  the  use  of  nourishing  food,  principally  rich 
soups  and  roast  meats,  largely  supplied  with  ozmazome  and  fibrine. 
For  drink  we  may  prescribe  the  old  and  tonic  Burgundy  wines,  or 
the  Bordeaux  and  Rhenish,  mixed  with  the  mineral  waters  of  Forges, 
of  Passy,  of  Provins,  of  Rouen,  of  Bussang,  of  Spa,  of  Bussiares,'*  and 
the  various  ferruginous  waters.  It  will  be  well,  likewise,  to  make  use 
of  bitter  and  gently  excitant  drinks,  of  dry  frictions,  flannel  next  to  the 
skin,  and,  finally,  of  cold  river-baths,  of  swimming,  exercise  on  foot 

* Bussiares  is  a village  situated  in  the  department  de  l’Aisne,  three  leagues  from 
Chateau-Thierry,  and  twenty-one  from  Paris.  Its  waters,  the  principal  sources  of 
which  belong  to  M.  Villacrosse,  and  of  which  M.  Corriol,  a distinguished  pharma- 
ceutist of  Paris,  has  lately  made  an  excellent  analysis,  are  situated  in  a charming 
spot,  where  one  breathes  the  purest  air.  For  this  last  reason,  they  are  preferable, 
when  taken  on  the  spot,  to  most  of  the  other  ferruginous  springs,  which,  almost  with- 
out exception,  are  in  damp,  unhealthy  and  marshy  districts.  We  have  had  it  in  our 
power,  as  well  as  Dr.  Eydoux,  to  witness,  on  several  occasions,  the  happy  effects  of 
the  waters  of  Bossiares,  in  cases  of  amenorrhoea,  chlorosis,  and  dropsy,  etc. 


474 


AMENORRHCEA. 


and  in  a carriage,  riding  on  horseback,  living  in  the  country,  mode- 
rate exercise,  the  games  of  battledore,  the  jumping-rope,  the  hoop, 
running,  and  particularly  dancing,  are  also  powerful  means  of  cure, 
which  ought  not  to  be  neglected,  and  which  women  seldom  object 
to  putting  in  practice.  We  should  also  endeavour  to  remove  the 
melancholy  of  our  patients  by  relieving,  as  much  as  possible,  their 
vexations  and  moral  disorders,  which  are  often  the  chief  causes  of  the 
debility  of  their  constitutions.  It  is  to  the  persuasive  eloquence  of 
friendship  that  we  must  trust  for  the  restoration  of  that  calm  and  peace 
of  mind,  without  which  all  other  means  will  remain  without  fruit. 

Though  a hygieinic  treatment  is  sufficient,  in  some  simple  cases,  to 
remove  amenorrhoea  depending  upoft  general  debility  of  the  consti- 
tion,  it  is  in  most  cases  necessary,  at  the  same  time,  to  resort  to  tonic 
medicines,  whose  action  influences  all  the  different  systems,  and 
especially  that  of  the  circulation.  Among  the  therapeutical  agents 
of  this  nature,  we  would  place  in  the  first  rank  iron  and  its  various 
preparations,  as  the  filings,  the  oxides,- the  tartrates,  and  the  carbo- 
nates of  this  metal,  employed  alone,  or  combined  with  the  bitter  pow- 
ders and  extracts,  with  Castile  soap,  cream  of  tartar,  or  some  salt  of 
potash,  etc.  We  ought,  however,  to  remark,  that  of  all  the  ferrugi- 
nous salts  ,the  subcarbonate  is  the  one  whose  efficacy  in  overcoming 
primitive  or  consecutive  amenorrhoea  depending  upon  constitutional 
debility,  is  most  generally  recognized.  This  remedy,  which  is  pre- 
scribed in  graduated  doses,  from  a few  grains  up  to  two  or  three 
drachms  daily,  gives  tone  to  the  whole  economy,  improves  the  haema- 
tosis,  equalizes  the  circulation,  and  by  re-establishing,  as  it  were,  by 
enchantment,  the  equilibrium  of  all  the  functions,  directs,  by  a special 
action,  an  afflux  of  blood  upon  the  uterus.  We  have,  in  this  condi- 
tion, and  always  with  advantage,  used  the  pills  of  Doctor  Eland,  of 
Beaucaire,  composed  and  administered  as  we  shall  describe  in  treat- 
ing of  chlorosis.  We  might,  also,  in  the  same  condition,  prescribe 
WherlofPs  pills,  made  according  to  the  following  formula,  viz.,  sul- 
phate of  iron,  two  drachms  ; extract  of  absinthium,  four  drachms : 
syrup  of  saffron,  q s.  to  make  one  hundred  and  fifty  pills.  If 
the  disease  should  seem  connected  with  a scrofulous  diathesis,  it 
would  be  well  to  recur  to  M.  Lugol’s  pills : take  of  protiodide  of 
iron,  six  grains ; starch,  twenty-four  grains ; syrup  of  gum,  q.  s. 
to  make  twenty-four  pills,  one  of  which  should  be  taken  morning 
and  evening.  If  the  amenorrhoea  should  be  complicated  with  chro- 
nic leucorrhoea,  which  is  sometimes  a substitute  for  the  menstrual 
discharge,  recourse  should  be  had  to  vaginal  injections  of  the  ferru- 
ginous waters  of  Forges,  of  Spa,  of  Passy,  etc.,  and  at  the  same  time 
should  be  prescribed  our  balsamic,  tonic  and  ferrated  troches,* 
which  are  perfectly  well  prepared  by  M.  Corriol,  of  whom  we  have 
already  had  occasion  to  speak  in  this  chapter.  These  troches  have 
the  double  advantage  of  being  very  efficacious  in  chronic  leucorrhoea, 
and  in  the  amenorrhoea,  dependent  upon  constitutional  debility. 

* We  shall  give,  at  the  end  of  this  work,  the  composition  and  mode  of  preparation 
of  our  troches,  into  which  enter,  in  different  proportions,  copaiba,  the  black  oxide  ot 
iron,  gentian,  rhubarb,  canella,  and  magnesia. 


AMENORRHCEA. 


475 


There  might,  likewise,  be  prescribed  with  advantage  in  this  case, 
the  internal  use  of  turpentine,  united  to  some  tonic  substance,  the 
efficacy  of  which  has  been  established  by  M.  Gibert,  [Rev.  Med., 
1837,  t.  iii.  p.  32.) 

For  the  cure  of  the  amenorrhoea  under  consideration,  there  is  not 
only  a crowd  of  other  martial  preparations,  such  as  the  vinum  ferri, 
the  martial  pills,  etc.,  but  also  a great  number  of  other  tonic  and 
stimulant  remedies,  among  others,  cinchona,  quassia,  gentian,  cen- 
taury, buck-bean, canella,  ginger,  cardamum,  absinthium,  mint,  balm, 
sage,  etc.,  etc.  Though  most  of  these  substances  are  efficacious  in 
some  cases  of  amenorrhcea,  we  think  they  should  be  resorted  to  only 
where  it  is  certain  that  the  alimentary  tractus  can  support  their  action 
without  injury. 

The  means  that  we  have  just  mentioned  should  not  be  employed, 
where  constitutional  amenorrhoea  depends  upon  excess  of  vital  power 
and  a state  of  general  plethora.  In  cases  of  this  kind,  we  most  fre- 
quently succeed  in  reproducing  the  menstrual  flux  by  diminishing 
the  richness  and  exuberance  of  the  blood  and  other  fluids,  by  means 
of  a more  or  less  rigorous  diet,  vegetable  regimen,  watery  drinks, 
mild  purgatives,  and  especially  by  the  aid  of  repeated  bleedings 
practised  mostly  a few  days  before  the  presumed  epoch  of  the  men- 
strual exhalation. 

If,  after  having  modified  the  constitution,  as  we  have  described,  the 
menses  should  fail  to  thake  their  appearance,  we  might  resort,  but 
with  the  utmost  circumspection,  to  the  remedies  ranged  in  the  class 
of  emmenagogues,  such  as  rue,  mugwort,  absinthium,  saffron,  savine, 
Fuller’s  pills,  and  those  of  Ruft'us,  which  are  prescribed  only  at  the 
approach  of  the  menstrual  epoch.  To  the  careful  use  of  these  sub- 
stances, it  would  be  well  to  add  the  employment  of  local  means 
capable  of  inviting  the  blood  towards  the  uterus,  such  as  foot- 
baths, hip-baths,  warm  enemata,  aromatic  fumigations,  fomentations 
of  the  same  nature  applied  to  the  external  genital  organs,  cups  about 
the  pelvis,  local  depletion  from  the  vulva,  or  general  bleedings  from 
the  inferior  extremities,  and  finally,  a great  number  of  other  reme- 
dies, to  which  we  shall  revert  haj^after.  We  merely  add,  that  in 
order  early  to  accustom  the  genual  organs  to  a sanguine  fluxion, 
we  should  make  use  of  the  jjbcal  means  we  have  just  pointed  out 
at  the  same  time  that  we  prescribe  a general  treatment.  In  re- 
fractory cases,  it  would.be  particularly  necessary  to  insist  upon  the 
employment  of  leeches,  to  the  number  of  four  or  six,  applied  to  the 
internal  surface  of  the  thighs,  or  on  the  outside  of  the  labia  majora, 
taking  care  to  renew  the  applications  several  times  at  the  approach 
of  the  supposed  epochs  of  the  menses.  M.  Lisfranc,  ( Bulletin  de 
clin.,  No.  5,  p.  148,)  who  advises  that  the  bites  should  not  be  allowed 
to  bleed  for  more  than  a quarter  of  an  hour,  prefers,  under  these  cir- 
cumstances, a bleeding  in  the  foot  of  two  to  four  ounces.  That  able 
practitioner  says,  with  reason,  that  to  succeed,  this  treatment  must 
often  be  employed,  at  each  menstrual  epoch,  for  several  months  in 
succession. 

In  order  to  produce,  sympathetically,  an  afflux  of  blood  towards 


476 


AMENORRHOEA. 


the  uterus,  several  practitioners  have  recommended  irritating  the 
mammas,  either  by  means  of  cups,  by  the  use  of  leeches  in  small 
numbers,'*  or  by  the  application  of  sinapisms  to  the  breasts.!  Se- 
veral instances  of  the  successful  employment  of  these  means  have 
been  published  in  the  journals,  and  mentioned  in  the  foot  note,  and 
in  the  fourth  volume  of  the  Archives  Generates  de  Medecine  for 
the  year  1831. 

The  treatment  of  amenorrhoea.  dependent  upon  a particular 
condition  of  the  uterus , varies  according  as  the  menstrual  disorder 
is  owing  to  engorgement,  to  atony,  or  to  some  accidental  or  some 
congenital  fault  of  the  gestative  organ. 

Uterine  engorgement , which  contra-indicates  all  the  emmena- 
gogues,  and  other  excitant  remedies  which  we  have  just  mentioned, 
should  be  treated  by  rest,  by  mild  diet,  by  bleeding  from  the  arm, 
baths,  emollient  drinks,  poultices,  demulcent  and  narcotic  enemata, 
and  finally,  by  all  the  remedies  which  we  pointed  out  at  page  297, 
while  speaking  of  simple  engorgement  of  the  uterus. 

When  the  non-appearance  or  suppression  of  the  menses  depends 
upon  a torpor  of  the  womb,  the  female,  being  in  other  respects 
well,  we  might,  with  the  view  of  exciting  them,  advise  cups  to  the 
hypogastrium,  the  groins  and  thighs  ; warm  douches  of  the  Bareges 
waters,  or  of  those  of  Aix  in  Savoy,  directed  to  the  outside  of  the 
pelvis  and  into  the  vagina  ; stimulant  enemata,  medicated  pessaries, 
electricity,!  galvanism,  ( Andrieux ,)  coitus^  flannel  drawers,  aro- 
matic hip-baths,  bathing  of  the  legs  knee  deep,  the  application  of  a 
small  cup  to  the  cervix  uteri, ||  when  the  hymen  allows  of  it;  we 
should,  at  the  same  time,  resort  to  the  methodical  employment  of 
the  active  emmenagogues,  as  for  example  rue,  savine,  saffron,  mug- 
wort,  hellebore,  aloes,  and  cantharides,  the  effects  of  which  must 
be  carefully  watched,  and  which  are  rendered  still  more  efficacious 
by  association  with  persons  of  the  other  sex,  by  visiting  balls,  the 
theatre,  and  finally,  all  the  circumstances  capable  of  arousing  the 
genital  organs. 

Amongst  other  remedies  proposed  for  the  treatment  of  chronic 
amenorrhoea,  we  ought  to  cite  -igdine,  the  efficacy  of  which  has 
been  proved  by  MM.  Coindet,  Dumeril,  Brera  of  Padua,  Magendie, 
Sablairoles,  Recamier  and  Trousseau,  as  well  as  by  ourselves. 
Doctor  Carron  du  Villards,  ( Bulletin  ther .,  Oct.  15,  1835,)  speaks  of 
having  seen  several  cases  of  amenorrhoea  yield  to  the  internal  em- 
ployment of  cyanuret  of  gold,  prepared  in  the  proportion  of  three 
grains  to  eight  ounces  of  alcoholic  water.  At  first  one  teaspoonful 

* Ch.  Loudon,  on  the  cure  of  amenorrhoea,  1832.  Repert.  de  clinique,  par  Carron 
du  Villards,  1834,  p.  304. 

f Patterson,  Gazett.  Med.,  1833,  p.  866. 

% Sigaud-Lafond,(</e  I'electr.  med.,  p.565,)  Mauduyt,  ( Trait  de  Veledr.med.)  Nauche, 
p.  659,  Ch.  Loudon,  ( on  the  cure  of  amenorrhoea , 1834.) 

§ Hippocrates,  Plato,  (m  prax.,  cap.  xiv.)  Hoffman,  ( med  rat.  syst.,  t.  iv.  p.  401, 
Cullen,  ( Elern . de  med.,  trad,  par  Bosquillon,  t.  ii.  p.  137,)  and  several  other  authors 
state,  that  the  first  appearance  of  menstruation  often  takes  place  after  the  first  con- 
jugal approaches. 

11  MM.  Chaponnier,  Piorry,  and  Amussat,  have  made  use  of  this  remedy,  which,  in 
our  opinion,  is  far  from  being  unobjectionable. 


AMENORRHCEA. 


477 


is  taken  morning  and  evening,  fifteen  days  before  the  supposed  period 
of  the  menses,  and  then  two  and  three  progressively.  Ergot,  also,  has 
been  employed  advantageously,  in  a dose  of  five  or  six  grains  daily, 
(Pauly,)  and  the  watery  extract  of  aconite,  (M.  West,)  in  the  dose  of 
from  one  to  eight  grains  progressively. 

Were  the  amenorrhoea  associated  with  a condition  of  extreme 
irritability,  or  with  excessive  action  of  the  uterus,  we  should  pre- 
scribe abstinence  from  coitus,  revulsive  bleedings  from  the  arm,  in- 
jections, emollient  and  narcotic  enemata,  and  poultices,  and  finally, 
various  kinds  of  sedatives,  and  particularly  opium.  Nervous  and  hys- 
terical symptoms,  and  neuropathic  disorders,  should  be  treated  by 
antispasmodics,  assafoetida,  camphor,  musk,  castor,  and  the  opiate 
preparations,  administered  especially  in  small  enemata.  Finally, 
we  conclude  what  we  had  to  say  upon  the  treatment  of  amenor- 
rhoea depending  upon  a local  cause,  by  adding  that,  that  which  is 
owing  to  atresia  of  the  uterus,  vagina  or  vulva,  or  a lesion  of  situa- 
tion of  the  gestative  organ,  requires  operations  which  we  have  else- 
where described.'* 

The  treatment  of  sympathetic  amenorrhoea  must  depend  on  the 
causes  which  have  given  rise  to  the  suppression.  When  the  amenor- 
rhoea has  been  consequent  on  circumstances  which  may  provoke  it  in- 
stantaneously, such  as  the  sudden  impression  of  cold,  it  is  necessary,  if 
we  are  called  at  the  very  beginning,  to  prescribe  the  use  of  warm  drinks, 
slightly  excitant  and  sudorific,  as  for  example  the  infusions  of  balm, 
of  mint,  of  elder  flowers,  &c.,  rest  in  bed,  the  application  of  warmth 
to  the  thighs  and  legs,  kept  up  by  means  of  bottles  filled  with  warm 
water,  or  still  better  by  a poultice  of  flaxseed  meal,  enveloping  the 
whole  of  the  inferior  extremities,  and  renewed  as  soon  as  it  begins  to 
cool : in  cases  of  this  kind,  the  following  potion  has  always  seemed 
efficacious  in  our  hands ; take  of  distilled  balm- water  and  of  orange- 
flower  water,  each  two  ounces;  spirits  of  Mindererus,  three  drachms; 
tincture  of  saffron,  thirty  drops  ; syrup  of  tolu  and  orange-peel,  an 
ounce  each,  of  which  a tablespoonful  may  be  taken  every  half  hour. 
We  may,  likewise,  employ  with  advantage,  dry  cupping  to  the  hy- 
pogastrium  and  upper  part  of  the  thighs,  and  particularly  the 
veniouses  monstres,  that  is  to  say,  the  apparatus  of  Doctor  Sunot,t 

* At  the  sitting  of  the  20th  March,  1838,  Professor  Roux  read  to  the  Academy  of 
Medicine,  the  account  of  his  scientific  journey  in  Germany,  where  reference  is  had  to 
a curious  case  observed  at  Prague,  at  the  clinic  of  M.  Fritz,  in  a young  person  twen- 
ty-six years  of  age,  whose  uterus  presented  a development  equal  to  that  of  a woman 
pregnant  at  seven  months;  this  anormal  condition  was  produced  by  an  accumula- 
tion of  the  menstrual  blood,  which  could  not  be  discharged  because  of  a congenital 
obliteration  of  the  cervix  uteri,  and  absence  of  the  inferior  portion  of  the  vagina. 
Having  been  consulted  by  M.  Fritz,  M.  Roux  advised  the  opening  of  the  pouch 
through  the  vagina  by  careful  incisions  with  a bistoury.  The  advice  of  the  celebra- 
ted French  surgeon  was  adopted  with  complete  success.  Analogous  operations  have 
been  performed  by  Professor  Flammand,  MM.  Willaume,  of  Metz,  Amussat,  Stoltz, 
and  some  other  surgeons  whom  we  quoted  in  Chapter  V.,  First  Section,  (lesions  of 
form.) 

f Some  interesting  details  upon  the  application  of  the  ventouses  monstres  may  be 
found  in  a memoir  published  by  Doctor  Sunot,  in  the  number  of  the  Revue  Medicate , 
for  September,  1834,  under  the  title  of  Physiological  and  Therapeutical  Researches  on 
the  effects  of  the  compression  and  rarefaction  of  the  air , both  upon  the  body  and  limbs 


478 


AMENORRHCEA. 


in  which  the  inferior  extremities,  as  far  as  the  pelvis,  should  be 
engaged  ; this  method  is  so  powerful,  that  we  have  seen  it,  in  a case 
of  cerebral  congestion,  produce  uterine  haemorrhage  in  a woman  fifty 
years  of  age,  who  had  ceased  to  be  regulated  for  several  years.  To 
avoid  the  inconveniences  which  might  result  from  the  application  of 
this  ingenious  means,  particularly  that  of  .too  sudden  a derivation, 
the  precaution  should  always  be  observed  of  acting  slowly  and 
effecting  the  rarefaction  of  the  air  in  a gradual  manner.  The  method 
of  M.  Patterson,  which  had  already  been  usefully  employed  by  M. 
Velpeau,  and  which  consists  in  the  application  of  sinapisms  to  the 
breasts,  might  also  have  some  good  effect.  Where  the  suppression 
has  resulted  from  some  vivid  emotion,  antispasmodics  and  sedatives 
should  be  conjoined  with  these  means. 

The  treatment  of  amenorrhoea, , dependent  upon  a visceral  lesion, 
ought  to  consist  in  combating  the  disease  which  sustains  and  has 
given  rise  to  the  suppression  or  primary  non-appearance  of  the 
menses.  The  most  successful,  and,  at  the  same  time,  rational  mode 
is  first  of  all  to  allay  the  irritation  of  the  organs  primarily  affected  ; 
we  should  not,  therefore,  concern  ourselves  with  the  absence  of  the 
menstrual  discharge,  except  merely  with  the  view  of  diminishing  the 
severity  which  it  lends  to  the  existing  affection,  and  to  ^pcrease  the 
chances  of  cure  by  diverting  as  much  as  possible  the  afflux  of  blo6d 
towards  the  organ,  whose  lesion  is  the  primitive  cause  of  the  ame- 
norrhoea. Irritation  and  congestion  of  the  heart,  lungs,  stomach, 
liver,  etc.,  require,  at  first,  the  treatment  appropriate  to  those  differ- 
ent affections,  and  afterwards  local  means  proper  to  recall  the  men- 
struae,  which  should  be  employed  chiefly  at  the  epoch  corresponding 
to  the  monthly  periods.  Vicarious  haemorrhages,  of  small  amount, 
not.  affecting  very  delicate  organs,  and  especially  those  already  of 
long  standing,  ought  to  be  treated  with  prudence  and  circumspection, 
and  perhaps  left  to  the  efforts  of  nature  alone ; if,  however,  they 
should  occur  from  organs  in  which  congestion  might  produce  fatal 
consequences,  it  would  become  necessary  to  relieve  the  patient  of 
them,  taking  care  not  to  arrest  them  suddenly:  after  producing  the 
discharge  of  the  menses  by  the  rational  means  we  have  mentioned, 
all  anormal  haemorrhages  will  disappear  spontaneously,  or  they  may 
be  suppressed  without  danger. 

We  shall  conclude  by  saying,  that  the  moral  condition  of  the  patient 
merits  as  close  attention  as  the  different  means  we  have  discussed, 
and  requires,  perhaps,  greater  sagacity  even  on  the  part  of  the  physi- 
cian. So  long  as  we  neglect  to  attend  to  the  state  of  the  mind,  the 
menstrual  disorders  depending  upon  diseased  mental  conditions,  and 
especially  upon  profound  dejection,  resist  all  the  resources  of  the  art ; 
all  the  doings  in  pharmacy  are  equally  powerless  to  oppose  the  ame- 

tvhen  isolated.  We  are  happy  to  have  the  opportunity,  in  this  place,  of  thanking  the 
ingenious  inventor  of  this  apparatus,  for  the  disinterested  zeal  with  which  he  applied 
it  upon  our  own  person,  during  an  attack  of  cephalalgia  and  insomnia,  brought  on 
by  excessive  labour  and  prolonged  loss  of  rest.  This  new  derivative  of  the  blood, 
whose  happy  results  we  have  witnessed,  procured  for  its  author  the  prize  of  two 
thousand  francs,  offered  by  the  Academy  of  Sciences  of  the  Institute. 


DYSMENORRHCEA. 


479 


norrhoea  of  a young  girl,  who  is  tormented  by  a disappointed  or 
unfortunate  love ! 

“Nullis  est  amor  medicabilis  herbis  !” 

The  consolations  of  a prudent  and  enlightened  mother,  the  counsels 
of  a kind  and  indulgent  friend,  and  especially  marriage,  where  the 
prostration  is  not  gone  to  such  an  extent  as  to  give  cause  to  fear  for 
pregnancy  and  labour,  such  are  the  means  which,  in  these  cases,  can 
arrest  the  disease  at  its  source. 

OF  DYSMENORRHCEA. 

We  understand  by  dysmenorrhcea  a state  of  thfe  menstrual  dis- 
charge, in  which  it  is  regularly  established,  but  is  preceded  or  ac- 
companied by  uterine  pains,  and  often  by  nervous  and  hysterical 
symptoms.  This  anormal  condition,  which  is  less  a disease  than  the 
painful  exercise  of  a function,  and  which,  according  to  M.  Lisfranc, 
is  often  hereditary,  may  be  either  idiopathic  or  symptomatic  of  a 
chronic  metritis,  with  or  without  engorgement. 

The  causes  of  idiopathic  dysmenorrhoea  are  but  little  known  ; it 
has  been  noticed,  however,  that  those  women  who  furnish  the  most 
frequent  examples  of  it,  are  generally  of  a nervous  or  bilious  tem- 
perament, of  ardent  feelings,  and  greatly  addicted  to  coitus ; yet 
constitutions  precisely  the  opposite  of  this  are  not  exempt  from  it ; 
and  it  has  often  been  observed  that  changes  of  climate,  of  mode  of 
life,  of  habitation,  and  various  debilitating  causes,  which,  by  long- 
continued  action,  produce  amenorrhcea,  are  likewise  causes  of  the 
difficult  and  painful  discharge  of  the  menstrual  fluid. 

The  symptoms  which  constitute  a case  of  dysmenorrhoea  are  : 
pains  in  the  loins  and  groins,  in  the  hypogastric  region,  in  the  thighs, 
and  a kind  of  contraction  of  the  uterus,  which  precede  and  accom- 
pany the  flow  of  the  menses.  To  these  symptoms,  which  are  always 
present,  are  added  others  which  sometimes  fail  to  appear ; such  are 
a condition  of  hystericismus  and  anxiety,  a sense  of  constriction 
in  the  throat,  of  lassitude  of  the  limbs,  more  or  less  complete  insom- 
nia, and  a very  variable  temper.  Most  of  the  patients  feel  a sen- 
sation of  heat  in  the  neck  of  the  womb,  a kind  of  pruritus  of  the 
vagina  and  spasmodic  constriction  of  the  vulva,  giving  rise  to  erotic 
desires.  Nevertheless  coitus,  far  from  being  agreeable,  is  then  very 
painful  and  irritating  ; moreover,  the  discharge  of  blood  takes  place 
only  drop  by  drop,  and  though  sometimes  abundant,  it  is  always 
accompanied  with  a great  deal  of  pain. 

Symptomatic  is  much  more  common  than  idiopathic  dysmenor- 
rhma  ; its  most  frequent  cause  is  engorgement  of  the  neck,  and  espe- 
cially of  the  body  of  the  uterus,  which  may  be  ascertained  by  means 
of  the  Touch  practised  during  the  intervals  between  the  menstruse. 
The  incomplete  and  painful  discharge  of  the  menses  may  likewise 
be  symptomatic  of  some  lesion  of  a distant  organ,  and  like  amenor- 
rhoea,  there  is  no  chronic  disease  which  may  not  give  rise  to  it. 

The  treatment  of  idiopathic  dysmenorrhoea,  or  that  which  we  may 


480 


DYSMEXORRHCEA. 


regard  as  dependent  upon  a neurosis  of  the  uterus,  and  excessive 
sensibility  of  that  organ,  presents  as  the  first  indication  the  allaying 
of  the  nervous  condition  by  the  use  of  prolonged  warm  baths,  and 
particularly  hip-baths,  employed  several  days  before  the  menstrual 
epoch  ; opiate  enemata,  narcotic  injections  of  cicuta  and  henbane, 
when  the  pruritus  is  very  severe, or  simply  mucilage  of  marshmallows 
with  infusion  of  poppy-heads,  when  the  heat  alone  of  the  parts  is 
augmented  ; emollient  drinks  in  large  quantity,  vegetable  diet,  mild 
regimen ; finally,  if  the  female  is  plethoric,  a revulsive  bleeding, 
during  the  interval  of  the  menses,  or  still  better,  two  or  three  days 
before  their  appearance ; such  are  the  means  whose  efficacy  in  the 
treatment  of  the  affection  under  consideration  has  been  tested  by 
experience.  In  very  irritable  women,  we  should  add  to  these  means 
the  internal  employment  of  sedatives;  amongst  others  the  potions  and 
emulsions,  which  contain  either  extract  of  opium  in  minute  doses, 
or  syrup  of  white  poppies  or  acetate  of  morphia,  in  the  proportion 
of  a quarter  of  a grain  to  four  ounces  of  fluid,  which  should  be  taken 
in  the  dose  of  a tablespoonful  every  hour.  Finally,  with  the  view  of 
producing  a more  rapid  sedative  action  upon  thje  uterus,  and  to 
overcome  the  painful  tormina  which  accompany  the  discharge,  we 
might,  after  the  example  of  M.  Masuyer,*  M.  J.  Cloquet, f Patin,  of 
Troyes, % and  some  other  practitioners,  we  might,  we  say,  as  we  have 
several  times  done  with  advantage,  give  from  forty  to  seventy  drops 
of  the  acetate  of  ammonia,  ( spirit  Minderer.)  in  a glass  of  water, 
taken  at  two  doses.  The  administration  of  this  remedy  allays  the 
pain,  and  in  that  way  facilitates  the  flow  of  the  menses.  As  soon 
as  the  malaise  and  uterine  pains  are  felt,  the  first  dose,  (twenty- 
five  to  thirty-one  drops,)  should  be  administered;  half  an  hour  after  a 
second  quantity  is  ordered ; finally,  if  the  symptoms  do  not  improve,  a 
third  dose  is  prescribed,  but  that  should  be  done  with  the  same  reserve, 
in  order  to  avoid  what  sometimes  results  from  it,  a diminution  in  the 
quantity  of  the  menses.  We  shall  conclude  by  saying,  that  amenor- 
rhoea  is  often  rebellious  to  therapeutical  means,  especially  when 
hereditary,  and  in  some  sort  connected  with  the  primary  organiza- 
tion of  the  womb.  Dysmenorrhcea,  symptomatic  of  disease  of  this 
viscus,  or  of  a distant  organ,  offers  the  same  prognosis  as  the  primary 
affection,  and  requires,  therefore,  the  same  treatment  as  the  last. 

[Here  is  no  notice  taken  of  the  very  ingenious  theory  on  dysmenorrhoea, 
by  Dr.  Mackintosh,  in  his  Practice  of  Physic,  p.  686.  Dr.  Mackintosh,  it 
seems,  as  long  ago  as  1823,  had  met  with  much  difficulty  and  embarrass- 
ment in  the  treatment  of  cases  of  dysmenorrhoea,  when,  having  thought  that 
he  perceived  in  such  cases  the  signs  of  stricture  in  the  canal  of  the  cervix 
uteri,  he  imagined  that  to  dilate  that  canal  with  the  bougie,  might  be  a method 
of  relieving  the  pain  of  the  patient.  In  the  course  of  a few  years,  from 
1826  to  1832,  he  met  with  twenty  cases  of  dysmenorrhsea,  which  he  treated 

* Gazette  de  Sante,  November,  1826. 

t Archives  gen.  de  Med.,  t.  xii.  p.  651. 

* Clinique  des  hopitaux,  t.  iii.  No.  15  and  16,  1828. 


DYSMENORRHCEA. 


481 


by  the  use  of  the  bougie,  and  in  eighteen  of  them  with  a most  marked  suc- 
cess; in  two  others,  without  advantage.  Ten  of  the  eighteen  were  married 
women,  of  whom  seven  afterwards  fell  with  child.  Eight  were  unmarried 
young  women  or  widows. 

As  it  is  well  known  that  strictures  of  the  urethra,  if  neglected  or  become 
inveterate,  produce  diseases  of  the  bladder  and  even  of  the  kidneys,  it  appears 
reasonable  to  suppose  that  too  great  a constriction,  or  narrowness  of  the 
cervical  canal,  might  come  at  last  to  establish  a permanent  irritation  in  the 
womb,  laying  the  foundation  for  the  complaints  in  question.  It  is  at  least 
certain  that  instances  are  met  with  of  great  alterations  in  the  form  and  size 
of  the  canal.  Dr.  Mackintosh  says  (p.  652)  that  in  1823,  a medical  friend 
presented  him  with  a preparation  of  the  uterus  and  its  appendages,  in  which 
the  os  uteri  was  so  small  as  scarcely  to  admit  of  the  introduction  of  a hog’s 
bristle,  and  that  he  has  obtained  many  preparations  taken  from  the  bodies  of 
people  dying  of  different  diseases,  particularly  phthisis,  and  whose  histo- 
ries prove  that  they  had  laboured  under  dysmenorrhcea  during  their  men- 
strual lives.  Some  are  so  small  as  scarcely  to  admit  a bristle,  and  others 
large  enough  only  for  a small  silver  probe.  I exhibited  two  such  specimens 
to  the  class  in  the  Jefferson  Medical  College,  in  1841,  and  I have  a cast  of 
one  in  papier  mache , by  Mons.  Thibaud,  of  Paris;  I have  also,  on  various 
occasions,  carried  out  Dr.  Mackintosh’s  suggestions  in  some  of  the  cases 
under  my  care.  I cannot  boast  of  success  equal  to  that  of  Dr.  Mackintosh, 
perhaps  because  I have  not  confined  myself  to  the  selection  of  cases  so 
strictly  as  he  may  have  done.  It  certainly  appears  to  me,  however,  that 
the  operation  has  been  productive  of  advantage  in  several  instances;  and  in 
two  ladies,  who  were  both  married,  and  who  had  painful  menstruation,  the 
dilatation  was  followed  by  relief,  and  in  both  of  them  the  health  was  so 
much  improved  that  they  have  continued  to  be  in  good  health  as  regards 
dysmenorrhcea;  both  of  them  have  had  children,  one  thrice,  and  the  other 
twice-— though  they  had  never  before  become  pregnant. 

The  operation  is  safe,  and  not  very  difficult  of  performance. 

The  woman  should  lie  across  the  bed,  or  near  the  foot  of  it,  with  the 
knees  drawn  upwards,  and  separated  with  a pillow.  A flexible  block-tin 
bougie  of  proper  size  is  next  to  be  conducted  along  the  right  index  finger  to 
its  point,  which  is  placed  on  the  os  uteri,  and  serves  to  guide  the  bougie  to 
the  canal  of  the  cervix.  If  the  bougie  be  somewhat  curved,  its  apex  enters 
without  difficulty,  and  passing  upwards,  slowly,  to  the  distance  of  one  inch 
and  a half  to  two  inches,  is  left  in  situ  for  a minute  or  two,  and  then  with- 
drawn, to  be  followed  by  one  of  a larger  size.  The  patient  complains  of  a 
sense  of  aching  in  the  region  of  the  uterus  if  the  instrument  selected  happen 
to  be  somewhat  of  a full  size;  and  I think  it  undesirable  to  give  any  pain 
whatever,  since  it  will  be  found  that  a larger  and  still  larger  instrument  can 
be  passed  at  subsequent  operations,  without  distress. 

It  is  proper  to  advert  in  this  place  again  to  the  new  theory  of  menstrua- 

31 


482 


DYSMENORRHCEA. 


lion,  which  has  been  the  subject  of  two  notes  in  this  volume.  Very  certainly 
many  women  do  complain  of  the  dysmenorrhcea-pain  as  situated  in  the  ovary, 
sometimes  on  the  right,  and  sometimes  on  the  left  side.  I was  recently  pre- 
sent during  the  severe  dysmeriorrhcea-pain  experienced  by  a patient,  which 
she  referred  to  the  left  ovarian  region — and  she  told  me  that  she  was  in  the 
habit  of  suffering  sometimes  on  one,  and  sometimes  on  the  other  side,  but 
never  in  both  iliac  regions  at  once.  I should  think  there  could  be  little 
doubt  that  the  pain  in  such  case  is  the  result  of  the  exalted  sanguine  and 
nervous  force  of  one  of  the  ovaria  and  tubes,  coincident  with  the  mensual 
hyperaemia,  and  completed  development  and  rupture  of  a Graafian  vesicle. 
In  such  a case,  the  therapeutical  treatment  indicated  would  be  the  subduc- 
tion  of  such  vital  augmentations — to  be  effected  by  venesection,  by  cooling 
aperients,  by  baths,  fomentations,  cataplasms,  by  the  application  of  leeches 
along  the  region  of  the  round  ligament,  and  by  a blister  in  anticipation. 
This  method,  with  the  calming  and  restraining  influence  of  the  anodyne 
enemata  or  suppository  would  suffice,  together  with  the  proper  hygieinic  pre- 
cautions as  to  dress,  diet  and  exercise,  probably  to  overcome  the  morbid 
tendency  of  the  functions.  I shall  take  advantage  of  this  opportunity  to  set 
forth  a few  laws  upon  the  subject  of  menstruation  and  reproduction,  as  laid 
down  by  M.  Pouchet,  of  Rouen,  in  his  Theorie  Positive  de  la  Fecondation 
des  Mammiferes,  4"C.  Paris,  1842,  8vo.  p.  161.  I have  not  had  an  oppor- 
tunity to  see  M.  P.’s  work  until  to-day.  He  lays  down  certain  fundamental 
physiological  laxvs,  as  follows : 

Law  I.  There  is  no  exception  in  favour  of  the  human  race ; the  pheno- 
mena of  human  generation  obey  laws  analogous  to  those  of  the  mammals. 

Law  II.  In  all  animals,  generation  is  effected  by  means  of  ova : some 
inferior  creatures  furnish  exceptions  to  this  law. 

Law  III.  In  all  the  animal  series,  ovula  pre-exist  to  fecundation. 

Law  IV.  Physical  obstacles  prevent  the  seminal  fluid  from  coming  into 
contact  with  the  ovula  while  within  the  Graafian  vesicle. 

Law  V.  In  the  entire  series  of  animals,  the  ovary  incontestably  emits 
ova  independently  of  fecundation. 

Law  VI.  In  all  animals,  the  ovary  emits  ova  at  determinate  epochs  con- 
nected with  a periodical  sur-excitement  of  the  genital  organs. 

Law  VII.  Fecundation  never  takes  place  in  a mammal,  except  where  the 
emission  of  ova  coincides  with  the  presence  of  the  seminal  fluid. 

Law  VIII.  The  emission  of  the  catamenial  discharges  in  women  corre- 
sponds with  the  phenomena  of  excitation  observable  in  the  mammalia  during 
the  rut  of  the  zoological  species,  and  particularly  in  the  females  of  the  mam- 
malia. 

Law  IX.  Fecundation  has  a constant  relation  to  the  discharge  of  the 
menses.  It  is,  moreover,  easy  to  point  out  the  inter-menstrual  period, 
wherein  conception  is  physically  impossible,  and  also  that  wherein  it  is 
probable. 


IMMODERATE  FLOW  OF  THE  MENSES. 


483 


Law  X.  There  are  certainly  no  ovarian  pregnancies,  properly  so  called. 

Additional  physiological  laws. 

Law  L Fecundation  in  mammals,  when  normal,  occurs  in  the  womb. 

Law  II.  Abdominal  and  tubal  pregnancy  do  not  prove  that  fecundation 
takes  place  in  the  ovary,  nor  that  this  is  what  determines  the  emission  of  the 
menses. 

Law  III.  The  Fallopian  tubes  do  not  normally  contract,  except  from  the 
interior  towards  the  exterior  of  the  body,  for  the  transmission  of  the  ovu- 

lum. — M.]* 

OF  IMMODERATE  FLOW  OF  THE  MENSES  AND  OTHER  UTERINE 
HAEMORRHAGES. 

We  ought  to  comprehend,  under  the  terms  floodings  or  uterine 
haemorrhages  only  the  excessive  or  immoderate  sanguine  discharges 
which  take  place  from  the  external  orifice  of  the  uterus,  either  in  its 
non-gravid  state,  or  during  pregnancy  and  labour.  As  our  intention 
is  to  treat,  in  this  work,  only  of  the  haemorrhages  connected  with  the 
diseases,  properly  so  called,  of  the  uterus,  we  shall  pass  by,  in  silence, 
those  occurring  during  gestation  and  delivery,  but  propose  noticing 
them  in  another  treatise,  independent  of  this,  to  be  published  after  a 
time. 

Uterine  haemorrhages  occur  in  women  who  are  still  regular  and 
also  in  those  who  have  ceased  to  be  so  when  connected  with  the 
appearance  of  the  menses ; that  is  to  say,  when  the  loss  of  blood  is 
nothing  more  than  menstruation  itself,  carried  beyond  the  healthful 
point,  the  discharge  is  specially  designated  untler  the  term  menor- 
rhagia, while  it  takes  that  of  metrorrhagia , when  it  appears  at  any 
other  epoch  than  that  of  menstruation:  in  menorrhagia  or  hyperme- 
norrhoea,  the  blood  flows  at  each  menstrual  period  in  greater  abun- 
dance than  natural : there  are  some  cases  in  which  the  quantity  of 
blood  remains  the  ^me  during  a given  period ; but,  nevertheless,  the 
discharge  becomes  superabundant,  because  it  lasts  a greater  or  less 
number  of  days.  In  some  women,  the  periods  of  menstruation 
approximate  to  each  other  to  such  an  extent  that  there  remains 
scarcely  any  interval  between  them.  In  others,  the  different  varie- 
ties of  hypermenorrhoea  are  blended  together,  so  that  the  menses 
recur  not  only  more  frequently,  but  also  more  abundantly,  and  re- 
main during  a longer  period  than  usual.  Finally,  there  is  another 
kind  of  menorrhagia  that  Aetius  has  designated  by  the  title  of  stilli- 
cidium  uteri;  and  other  authors,  by  that  of  menorrhagia  stillati - 
tia,  which  consists  of  a sanguine  excretion,  small  in  quantity,  but 
prolonged  to  such  an  extent  as  to  become  in  some  sort  continual,  so 
that  the  epochs  corresponding  to  the  menstrual  periods  are  no  longer 
distinguished  except  by  the  greater  abundance  of  the  discharge  and 
by  the  redder  colour  and  firmer  consistence  of  the  fluid  thrown  off. 

While  women  of  considerable  embonpoint  ordinarily  lose  but 
little,  those  who  are  thin  and  delicate  generally  have  abundant  men- 
struse,  and  are  more  disposed  to  menorrhagia  than  the  strong  and 


4S4 


IMMODERATE  FLOW  OF  THE  MENSES. 


sanguine  : there  are  some,  indeed,  who  might  be  traced  by  the  marks 
which  they  leave  for  several  days,  even  when  provided  with  napkins 
and  cloths.  The  blood,  which  escapes  in  a full,  free  stream,  as  it  were, 
compels  them  to  remain  in  bed,  and  this  the  more,  as  the  loss  reduces 
them  to  a condition  of  extreme  feebleness.  Women  of  this  kind  of 
constitution  are  in  the  habit  of  calling  themselves  very  sanguine, 
because  they  judge  of  their  temperament  by  the  exuberance  of  their 
menstruation. 

A consideration  of  the  amount  of  blood  lost  by  a female  at  each 
periodical  epoch,  is  a faulty  mode  of  judging  whether  the  uterine 
exhalation  is  in  a normal  condition,  or  whether,  on  the  contrary, 
hypermenorrhcea  is  commencing.  It  is  impossible  to  have  a certain 
standard,  and  we  think  that  the  quantity  of  the  sanguineous  discharge 
is  a measure  the  more  inexact,  because  a considerable  loss  often  pro- 
duces no  unfavourable  symptom  in  a plethoric  female,  while  a men- 
strual discharge  of  moderate*  quantity  is  sometimes  sufficient  to 
debilitate  a feeble  person.  Nevertheless,  we  should  regard  as  mor- 
bid, the  uterine  haemorrhages  which  appear  at  any  other  epoch  than 
that  of  menslruation,  as  well  as  all  the  sanguine  exhalations  from 
the  womb,  which,  far  from  alleviating  and  inducing  well-being,  pro- 
duce feebleness,  paleness,  malaise,  and  which,  lasting  longer  than  the 
ordinary  time,  are  followed  by  coldness  of  the  extremities,  syncope, 
and  convulsions.  The  guide  to  direct  the  physician,  in  judging  of 
immoderate  flow  of  the  menses,  is  therefore  less  the  quantity  of 
blood  that  flows,  than  the  strength  or  languor  of  the  patients.  We 
therefore  should  not  regard  a menstrual  discharge  as  morbid,  which, 
though  very  abundant,  exerts  no  unfavourable  influence  upon  the 
health  of  the  womarf. 

[Nothing  can  be  more  various  than  the  quantity  of  blood  lost  by  different 
women,  in  their  menstrua.  There  are  many  females  who  enjoy  the  most 
perfect  menstrual  health,  and  who  never  find  themselves  obliged  to  wear  any 
napkin  for  the  reception  of  the  discharge,  but  suffer  it  to  fall  on  their  ordi- 
nary dress;  but  this  could  not  be,  without  the  most  glaring  exposure,  were 
the  quantity  to  be  considerable.  On  the  other  hand,  I am  told  by  many 
females,  that  the  discharge  for  them  requires,  from  first  to  last,  some,  fifteen, 
and  some  even  as  many  as  twenty  napkins  ; so  that  I infer  that  some  women 
are  sufficiently  regulated  with  three  ounces,  while  others  require  a depuration 
amounting  to  fifteen  ounces,  or  even  twenty  ounces,  at  each  catamenial 
period.  Hence  it  appears  that  each  woman  obeys  a law  of  her  own  consti- 
tution, and  that  the  object  of  the  physician  should  be  to  learn  what  is  her 
particular  rate.  Having  done  so,  he  becomes  a fitting  judge  of  what  is  devi- 
ation, by  excess,  or  by  diminution.  I have  seen  a girl  of  fifteen  aetat.  use 
sixty  napkins,  soaked  full,  for  each  menstruation,  without  appearing  to  be 
rendered  unwell  by  the  loss. — M.[] 

As  metrorrhagia,  properly  so  called,  often  assumes  the  periodical 
character  of  menstruation,  and  may  be  blended  with  it,  it  is  difficult 
to  distinguish  certainly  these  two  sanguine  discharges ; some  authors 


IMMODERATE  FLOW  OF  THE  MENSES. 


485 


regarding  the  distinction  as  very  important,  and  resting,  moreover, 
upon  the  opinions  of  Celsus,  of  Hunter,  of  Dionis,  upon  the  experi- 
ments of  MM.  Mojon,  Davy,  Brande,  Lavagna,  Julia  Fonteneile, 
etc.,  have  asserted  that  the  menstrual  blood  does  not  coagulate,  and 
is  destitute  of  fibrin.  Though  the  works  of  modern  chemists  and 
physicians  seem  to  leave  no  doubt  as  to  the  permanent  fluidity  of 
the  menstrual  blood,  we  are  far  from  believing  all  that  has  been  said 
upon  this  subject ; for  all  the  females  in  good  health,  whom  we  have 
consulted  upon  this  matter,  have  told  us  that  they  have  sometimes 
expelled  clots ; besides,  M.  Lecanut  ( Etud . chim.  sur  le  sang.,  1837) 
has  proved  that  menstrual  blood  differs  from  ordinary  blood  merely 
in  the  respect  that  it  contains  some  mucus. 


[Dr.  Donne  examined  some  menstrual  blood  for  Dr.  Brierre  de  Boismont, 
and  found  ordinary  natural  blood  corpuscles  in  great  quantity,  and  epithelium 
scales  from  the  vaginal  mucous  membrane. 


Mr.  Denis  gives  this  analysis  of  the  blood  of  a girl  of  twenty-seven  aetat. : 


Water, 

Globules, 

Albumen, 

Extractive, 

\ 


825.00  I Fatty  matters,  . . . 3.90 

64.40  I Saline  “ ...  12.00 

48.30  I Mucus,  ....  45.30 

01.10  | 

Apud.  Brierre  de  Boismont,  op.  cit.,  p.  172. 


M.  Bouchardat,  in  a patient  of  35  set.,  found 


Water,  .... 
These  solids  were — 
Fibrine,  albumen  and  colouring 
matter,  .... 
Extractive, 


90.08  1 Solids, 


Fatty  matter,’ 
75.27  Salts, 

0.42  Mucus, 

Idem, 


6.92 


2.21 

5.31 

16.79 

M.] 


As  it  is  not  always  easy  to  make  the  differential  diagnosis  of  im- 
moderate flow  of  the  menses  and  of  metrorrhagia,  and,  moreover,  as 
these  two  uterine  haemorrhages,  which  are  confounded  by  most 
authors,  may  be  referred  to  the  same  points  of  doctrine,  and  require 
nearly  the  same  therapeutical  indications,  we  deem  it  proper  not  to 
separate  them  in  the  description,  in  order  to  avoid  the  constant  repe- 
titions that  would  occur  were  we  to  devote  to  each  a particular 
chapter.  We  shall  therefore  confine  ourselves  to  stating  that  women 
who  wish,  to  moderate  a too  great  abundance  of  the  menstruae, 
should  abstain,  during  the  period  of  their  flow,  from  all  violent  exer- 
cises, and  sometimes  even  maintain  a horizontal  position,  in  such 
a way  that  the  pelvis  may  be  rather  more  elevated  than  the  head 
and  trunk : those  of  strong  constitution  should  make  use  of  a milk  and 
vegetable  diet ; of  diluent,  cooling  and  acidulated  drinks,  as  currant 
water,  whey,  weak  lemonade,  decoctions  of  barley  or  of  dog’s  grass 
with  nitre,  mucilage  of  gum  arabic,  flavoured  with  lemon  syrup  or 
with  vinegar.  Women  of  a ner vo-lymphatic  temperament  must 
be  nourished  with  tonic  aliments,  principally  roast  meats,  and  they 
ought  to  use  as  drinks,  during  their  repasts,  water  mixed  with  a little 
generous  Rhenish  or  Bordeaux  wine.  There  might  also  be  directed 
for  them,  with  advantage,  narcotics  and  antispasmodics,  administered 


4S6 


METRORRHAGIA. 


in  minute  doses  during  the  continuance  of  the  function ; the  use  of 
cool,  or,  if  the  season  forbids,  of  warm  baths,  in  the  interval : in  either 
case,  small  revulsive  bleedings  from  the  arm,  a few  days  after  the 
menstrual  discharge,  to  be  repeated  between  each  periodical  epoch, 
will  contribute  powerfully  to  moderate  the  discharge  of  blood  from 
the  uterus. 


OF  METRORRHAGIA. 

For  the  reasons  just  given  while  speaking  of  excessive  flow  of  the 
menses,  we  shall  comprehend,  under  the  denomination  of  metror- 
rhagia, all  the  sanguine  discharges  of  the  uterus  which  take  place  at 
other  times  than  during  pregnancy  or  labour,  and  which  we  divide 
into  essential , sympathetic  and  symptomatic  haemorrhages. 

The  two  first  classes  include  all  discharges  of  blood  that  take 
place  without  wound,  erosion  or  appreciable  rupture  of  tissue,  and 
in  the  latter  are  found  those  which  constitute  secondary  phenomena, 
or  accidental  complications  of  some  more  serious  disease  which 
ought  particularly  to  fix  the  physician’s  attention. 

Essential  or  idiopathic  metrorrhagia,  that  is  to  say,  that  which, 
like  menstruation,  is  effected  by  the  mysterious  influence  of  an  un- 
known physiological  law,  may  appear  at  any  time  of  life ; for  it  has 
often  been  observed  to  occur  in  women  of  very  advanced  age,  in 
girls  who  were  not  yet  regulated,  and  even  in  children  of  seven 
years  of  age,  (Delamotte;)  of  three  years  of  age,  (Bourjot  Saint- 
Hilaire;)  of  nine  months,  (Clarke,  Nonv.  Bibliot.  Med.,  t p.  92, 
1829  :)  of  three  months,  (Comarmond  ;)  and  of  a few  days,  (Mallat, 
Gazette  Med.,  September,  1832.)  We  should  remark,  however,  that 
the  sanguine  exhalations  from  the  uterus,  which  appear  at  other  times 
than  during  the  fecundative  period  of  the  life  of  the  female,  are  very 
rare  exceptions. 

Essential  uterine  haemorrhage  may  be  active  or  passive.  The 
former,  or  active  metrorrhagia,  which  accompanies  plethora,  and 
occurs  during  the  mature  period  of  life,  has,  for  predisposing  causes, 
excessive  heat,  extreme  cold,  residence  in  large  cities,  the  inhabitation 
of  elevated  situations,  the  abuse  of  stimulating  dishes,  of  alcoholic 
liquors,  and  of  too  nourishing  food,  violent  passions,  indolent  mode 
of  life ; beside  all  those  that  are  common  to  other  haemorrhages,  we 
range  amongst  those  which  are  peculiar  to  active  metrorrhagia,  the 
epoch  of  the  menses  and  principally  those  two  at  which  this  discharge 
is  either  first  established,  or  should  finally  cease;  excessive  sensibility 
of  the  womb,  whether  primitive  or  acquired  by  the  abuse  of  coitus, 
of  masturbation,  or  from  any  other  cause ; finally,  frequent  child- 
bearing, the  use  of  foot-stoves,  the  abuse  of  emmenagogues,  of  acrid 
purgatives,  and  of  warm  baths,  all  properly  regarded  as  being  pre- 
disposing causes  of  active  metrorrhagia.  It  is  not  uncommon  to  see 
an  abundant  loss  of  blood  follow  a suppression  of  the  menses,  or 
occur  in  newly-married  persons,  especially  if  the  first  conjugal  ap- 
proaches take  place  a few  days  before  the  epoch  of  menstruation. 


METRORRHAGIA. 


487 


The  exciting  causes  of  active  metrorrhagia  are : violent  exercises, 
such  as  running,’ dancing,  riding  on  horseback,  the  jolting  of  a car- 
riage, a fall  on  the  feet,  on  the  knees,  and  especially  on  the  buttocks; 
excitants  applied  to  the  genital  parts;  the  efforts  and  concussions 
which  result  from  lifting  a burthen,  from  crying,  singing,  sneezing, 
coughing,  etc.  We  ought  to  remark,  however,  that  all  these  circum- 
stances act  most  powerfully  where  the  gestative  organ  has  been  for 
a long  time  the  seat  of  an  excess  of  vital  force  or  of  a local  plethora. 

The  causes  of  asthenic,  or  passive  metrorrhagia,  are  all  such  as 
may  cause  general  or  local  debility,  such  as  excessive  labour,  late 
hours,  the  depressing  passions,  grief,  immoderate  or  too  frequent 
menstruation,  diseases  of  long  duration,  protracted  lactation,  the 
habitual  use  or  abuse  of  aliment  of  improper  nature,  relaxing,  un- 
wholesome or  mucilaginous  drinks;  warm  mineral  waters,  warm 
baths,  and  emollient  or  warm  injections ; finally,  passive  uterine 
haemorrhage,  which  may  be  a consequence  of  labour  or  abortion 
repeated  in  quick  succession,  has  frequently  been  the  termination 
of  an  often-renewed  active  metrorrhagia,  or  has  even  been  the 
result  of  a treatment  for  this  affection,  in  which  bleedings,  refrige- 
rants, astringents  and  narcotics  have  been  improperly  used.  We 
add,  that  women  of  feeble  constitution,  of  lymphatico-nervous  tem- 
perament, and  those  who  have  laboured  under  some  scorbutic  disor- 
der, are  more  liable  than  others  to  the  sanguine  exhalation  of  which 
we  are  speaking. 

Sympathetic  uterine  haemorrhage  depends  upon  causes  which 
are  equally  worthy  of  arresting  the  attention  of  practitioners.  Those 
causes,  whose  action  first  falls  upon  other  organs,  produce  in  them 
disorders  which,  reacting  upon  the  womb,  occasion  uterine  haemor- 
rhages, which  are  really  sympathetic.  This  species  of  metrorrhagia 
is  the  more  readily  produced  in  proportion  as  the  organs,  first  dis- 
eased, have  a more  intimate  sympathy  with  the  uterus  ; wherefore, 
inflammations  of  the  stomach,  of  the  brain,  heart,  lungs,  liver,  intes- 
tines, etc.,  are  frequent  causes  of  uterine  haemorrhages.  Stahl,  [Med. 
prat.,  lib.  iii.,  p.  29,)  states  that  during  the  bilious  constitution, 
which  prevailed  in  1778,  uterine  haemorrhages  were  very  com- 
mon. Tourtelle,  also,  makes  mention  of  meningo-gastric  fevers, 
which  were  accompanied  by  an  abundant  serous  discharge  from  the 
vagina.  Fincke,  in  the  history  which  he  has  given  of  the  epidemic 
of  Techlenbourg,  says  that  menorrhagia  was  very  common,  and  that 
menstruation  experienced  an  unfavourable  influence  from  the  bilious 
affection.  Ziegert  [Dissert,  sur  Vemploi  despurg.  dans  la  mlnor- 
rha<ri.e),  has  seen  an  intestinal  irritation  produce  sympathetically  a 
sanguine  exhalation  from  the  uterus;  Vander  Bosch  has  also  ob- 
served, that  the  same  effect  was  produced  by  the  presence  of  worms 
in  the  digestive  tube  ; finally,  the  irritation  of  the  breasts  caused  by 
a sinapism,  the  application  of  leeches,  or  even  the  suckling  of  the 
child,  has  brought  haemorrhages  from  the  uterus,  and  has  repro- 
duced the  suppressed  menstruee.  Moreover,  all  circumstances  capa- 
ble of  imparting  a sudden  shock  to  the  innervation,  such  as  joy,  grief, 


488 


METRORRHAGIA. 


anger, * fright,  the  sudden  announcement  of  bad  news,  have  often 
been  the  causes  of  sympathetic  metrorrhagia. 

It  is  well  to  say,  that  the  losses  resulting  from  these  last  causes, 
are  met  with  more  particularly  in  nervous  women,  who  allow  them- 
selves to  be  agitated  by  the  slighest  events,  and  who  are,  as  Hoffman 
says  : “ activae  et  sensibilioris  naturae,  vet  etiam  hypochondriasis  et 
hystericis  passionibus  obnoxiae 

However  numerous  the  causes  we  have  just  mentioned,  they  are 
not  those,  nevertheless,  which  most  frequently  produce  haemorrhage 
from  the  uterus.  Indeed,  haemorrhages  from  the  gestative  organ 
are,  in  the  great  majority  of  cases,  the  symptoms  of  a local  affection, 
such  as  acute  or  chronic  metritis,  simple  hypertrophy,  scirrhous  en- 
gorgement, and  especially  sanguine  engorgement,  polypous  tumours, 
simple,  scrofulous,  tubercular,  venereal,  carcinomatous,  and  fungous 
ulcerations;  finally,  inversion  of  the  uterus,  and  a number  of  other 
lesions  of  the  organ,  which  have  been  discussed  in  this  work.  Symp- 
tomatic metrorrhagia  is  also,  in  some  cases,  the  unfortunate  result  of 
scorbutic,  eruptive,  typhoid,  and  pestilential  diseases,  and  of  malig- 
nant intermittents. 

The  course  and  precursory  phenomena  of  uterine  haemorrhages 
vary  according  to  the  causes  which  have  produced  them.  Those 
which  are  the  effects  of  predisposing  causes  pursue  a slow  progress, 
and  are  generally  established  either  by  a successive  augmentation  in 
the  quantity  and  duration  of  the  menstrual  discharge,  or  by  the  ap- 
proximation of  the  menstrual  periods.  In  some  cases,  the  haemor- 
rhage reappears  a few  hours  after  its  cessation  ; in  others,  it  returns 
every  day,  every  two  days,  every  three  days,  and  assumes  the  quo- 
tidian, tertian  or  quartan  type  ; finally,  there  are  cases  in  which 
the  returns  appear  only  every  eight  days,  once  a month,  and  every 
three  months.  The  influence  of  habit  is  so  powerful,  that  essential 
uterine  haemorrhages  are  often  renewed  in  the  same  order,  and  with 
the  same  conditions  that  first  gave  rise  to  them. 

When  the  metrorrhagia  has  been  produced  by  a violent  exciting 
cause,  the  discharge  appears  either  immediately,  or  which  is  most 
common,  a few  moments  after  the  action  of  that  cause.  In  either 
case,  the  uterine  loss  may  take  place  with  such  violence,  that  the  life 
of  the  female  is  soon  exposed  to  the  greatest  danger,  especially  if  the 
accident  has  happened  at  the  epoch  of  menstruation.  This  metror- 
rhagia, which  may  be  called  accidental,  does  not  commonly  return 
after  it  has  once  been  overcome. 

Although,  in  some  cases,  the  precursory  symptoms  of  essential  me- 
trorrhagia are  confined  to  a few  uterine  pains,  like  those  felt  at  the 
menstrual  epochs,  it  happens,  most  frequently,  that  the  sanguine 
flow  is  preceded  by  various  phenomena;  amongst  others,  by  a sense 
of  tension,  of  fulness,  of  heat,  of  weight,  and  pain  in  the  pelvis  and 
hypogastrium  ;•  these  symptoms  ordinarily  coincide  with  swelling  of 
the  breasts,  frequency  and  fulness  of  the  pulse,  obstinate  constipa- 

* Doctor  Rondelou,  ( Dissert . inaug.)  quotes  from  M.  Alibert,  the  case  of  a female 
endowed  with  very  great  sensibility,  who, every  time  that  she  gave  way  to  transports 
of  anger,  was  attacked  with  violent  haemorrhage  from  the  uterus. 


METRORRHAGIA. 


489 


tion  and  general  lassitude  ; finally,  paleness  of  the  face,  coldness  of 
the  extremities,  shrinking  and  horripilation  of  the  surface,  heat  and 
pruritus  of  the  genital  parts,  are  signs  which  indicate  the  approach 
of  active  haemorrhage.  The  flow  of  blood,  which  soon  follows 
these  last  symptoms,  at  first  restores  calm  and  quiet ; but,  where  the 
amount  is  greater  than  the  state  of  the  strength  permits,  the  woman 
experiences  a sensation  of  sinking  in  the  region  of  the  stomach,  the 
pulse  becomes  feeble,  and  soon  hardly  perceptible,  the  lips  become 
white,  the  face  pale,  vision  is  obscured,  the  hearing  more  and  more 
obtuse,  respiration  is  embarrassed,  and  death,  the  approach  of  which 
is  heralded  by  lipothymia  and  convulsions,  often  comes  to  close  this 
startling  scene. 

Far  from  following  the  march  and  order  which  we  have  just 
traced,  consecutive  nervous  symptoms  sometimes  make  their  ap- 
pearance very  early,  and  we  see  them  arise  even  before  the  loss  of 
blood  has  been  very  abundant.  There  is  one  quite  frequent  conse- 
cutive phenomenon  in  particular,  which  is  sometimes  extremely  in- 
tense, and  persists  for  a long  time  after  the  haemorrhagic  discharge 
has  been  arrested.  In  cases  in  which  the  losses  of  blood,  without 
reaching  this  point,  are  frequently  renewed,  and  last  longer  than  the 
usual  period,  the  digestion  becomes  more  and  more  deranged,  the 
appetite  is  lost,  the  pallor  of  the  skin  resembles  that  which  is  met 
with  in  chlorosis,  the  eye-lids  are  swollen  and  surrounded  by  a dark 
areola,  the  inferior  extremities  become  oedematous,  serous  collections 
are  found  in  the  pleuric  and  peritoneal  cavities,  and  there  are  gene- 
rally added  to  the  unfavourable  symptoms  which  we  have  just  men- 
tioned, dull  pains  in  the  stomach,  and  various  nervous  disorders. 
We  should  remark,  however,  that  the  convulsions  and  syncope 
which  occur,  are  sometimes  advantageous  in  producing  a general 
spasmodic  condition,  which  throws  the  blood  upon  the  interior  of  the 
economy. 

In  passive  metrorrhagia,  the  blood  escapes  without  precursory 
signs,  and  flows  little  by  little  and  for  a long  time.  The  sanguine 
exhalation  is  not  preceded  by  any  symptoms  which  show  that  the 
action  of  the  uterine  vessels  is  increased.  Finally,  the  frequent 
return  of  the  haemorrhage,  the  presence  of  an  abundant  leucorrhoea 
in  the  interval  of  each  new  appearance  of  the  discharge,  and  espe- 
cially the  persistence  of  the  loss,  the  pale  and  serous,  and  sometimes 
blackish  colour  of  the  secreted  fluid,  will  indicate  sufficiently  the 
passive  and  asthenic  character  of  the  sanguine  flux. 

Though  the  diagnosis  of  metrorrhagia  is  commonly  readily  made 
out,  since  the  disease  declares  itself  by  the  escape  of  blood  and  the 
effects  produced  upon  the  economy,  it  is  not  always  easy  to  ascertain 
the  causes  which  give  rise  to  it,  and  which  keep  it  up.  Nevertheless, 
we  may  most  generally  succeed  in  recognizing  them  by  an  attentive 
examination  of  the  patient,  and  by  carefully  weighing  the  symp- 
toms along  with  the  commemorative  circumstances.  As  the  uterine 
haemorrhage  is  most  generally  the  symptom  of  a more  serious  disease, 
it  is  to  the  discovery  of  this  latter  that  the  physician  should  especially 
devote  himself.  It  becomes,  therefore,  indispensable  in  the  majority 


490 


METRORRHAGIA. 


of  cases,  to  proceed  to  the  examination  of  the  sexual  organs,  by  means 
of  the  Touch  and  the  speculum  uteri ; but  we  should  never  resort, 
in  the  very  commencement,  to  this  kind  of  exploration,  when  the 
female  is  very  nervous  and  easily  irritated,  although  the  diagnosis 
ought,  in  most  cases,  to  direct  the  practitioner  in  his  choice  of  means; 
we  shall  add  nothing  to  what  we  have  said  upon  the  particular  cha- 
racters of  each  kind  of  metrorrhagia. 

The  prognosis  of  uterine  haemorrhages  ought  to  be  based  upon 
the  causes  that  have  produced  them,  the  severity  of  the  symptoms, 
the  constitution  and  strength  of  the  subject,  and  finally,  the  duration 
of  the  disease.  The  passive  metrorrhagias  are  more  unfavourable, 
more  difficult  to  overcome,  and  more  liable  to  relapse  than  those 
which  are  active.  Those  that  depend  upon  transient  causes  cease 
commonly  of  themselves,  or  at  least  are  readily  cured ; if  they  ever 
appear  with  some  severity,  it  is  only  when  they  are  very  abundant. 
Ancient  haemorrhages,  which  seem  in  some  sort  to  have  habituated 
the  economy  to  frequent  losses,  are  the  most  rebellious  to  the  cura- 
tive means  which  are  opposed  to  them.  Those  which  come  on 
during  the  early  part  of  puberty,  almost  always  insensibly  cease  as 
menstruation  becomes  regular.  It  is  the  same  with  the  attacks  of 
metrorrhagia,  which  announce  the  critical  period;  they  generally 
disappear  spontaneously  so  soon  as  the  woman  has  reached  the 
normal  term  of  her  menstruation.  Finally,  metrorrhagia  sympto- 
matic of  a local  condition,  as  well  as  that  which  results  from  irrita- 
tion of  a distant  organ,  reacting  sympathetically  upon  the  uterus,  is 
dependent  upon  the  severity  of  the  disease  which  produces  them. 
Let  us  add,  in  order  to  terminate  what  we  had  to  say  upon  the 
prognosis,  that  active,  intermittent,  and  often-repeated  haemorrhages, 
are  usually  unfavourable,  rather  because  they  become  the  source  of 
a number  of  very  serious  lesions  of  the  womb,  than  because  they 
make  the  whole  economy  feel  their  pernicious  influence.  Finally, 
we  remark  that  the  critical  metrorrhagias  generally  announce  a 
favourable  termination  of  acute  diseases,  but  that  in  eruptive  dis- 
eases, as  in  adynamic  fevers,  they  are  the  indices  of  great  prostration 
of  the  strength,  and  augment  the  gravity  of  the  prognosis. 

The  treatment  of  uterine  haemorrhages  presents  three  principal 
indications  to  be  fulfilled,  which  are  : I,  to  remove  the  causes,  if  they 
be  still  present,  and  will  yield  to  the  powers  of  art;  2,  to  arrest,  the 
discharge  in  severe  cases  ; 3,  to  prevent  the  return  of  the  haemor- 
rhage. 

It  is  useless  to  recapitulate  all  the  causes  of  metrorrhagia,  in  order 
to  point  out  the  means  of  removing  or  overcoming  them  ; there  are 
some,  however,  upon  which  we  deem  it  proper  to  insist  by  devoting 
to  them  a particular  examination. 

Active  uterine  haemorrhage,  which  depends  upon  general  plethora, 
and  which  often  finds  a remedy  in  itself  by  the  mere  fact  of  the  loss 
of  blood,  requires,  in  the  majority  of  the  cases,  one  or  two  revulsive 
bleedings  from  the  arm.  The  local  plethora,  which  often  exists, 
independently  of  the  general  plethora,  likewise  demands  the  same 
means,  but  we  ought  not  to  be  in  too  great  haste  to  arrest  the  flow 


METRORRHAGIA. 


491 


of  blood,  which  is  sometimes  of  great  use  in  preventing  inflamma- 
tion of  the  womb.  We  should,  however,  in  all  cases,  prescribe 
absolute  rest  on  mattresses  of  hair  or  straw,  arranged  in  such  a way 
that  the  pelvis  may  be  somewhat  higher  than  the  rest  of  the  body. 
The  patient,  who  should  be  kept  in  perfect  quiet  and  in  the  greatest 
tranquillity  of  mind,  ought  to  be  lightly  covered,  and  should  breathe 
fresh  air ; but  it  is  always  well  to  avoid  coldness  of  the  extremi- 
ties; the  efficacy  of  these  means  may  be  much  increased  by  ordering 
at  the  same  time  strict  diet,  or  at  least,  forbidding  any  aliment 
except  some  fruit  jellies,  or  rice-milk,  or  barley  or  some  other  amy- 
lacious  substance,  prepared  with  milk  or  water.  There  should  be 
prescribed,  at  the  same  time,  the  abundant  use  of  some  refreshing 
drink,  taken  cold,  such  as  whey  or  a decoction  of  dog-grass  with 
nitre,  or  of  rice,  of  apples,  green  apples,  oranges  sweetened,  of  syrup 
of  currants,  of  mulberries,  cherries,  vinegar,  of  quinces,  etc.  Were 
these  means  insufficient,  we  should  prescribe  a tisan,  made  with 
an  ounce  or  two  of  comfrey-root,  or  an  ounce  of  rhatany-root,  and 
sweetened  with  some  sedative  syrup  ; finally,  by  means  of  emol- 
lient enemata  with  honey,  of  suppositories  of  beurre  cle  cacao , and 
especially  by  mild  laxatives,  such  as  the  pulp  of  tamarinds,  or  of 
cassia  fistula,  or  cream  of  tartar,  (potassse  bitartras,  from  one  to  four 
drachms,)  we  should  combat  the  constipation,  which  is  hurtful  from 
the  expulsvie  efforts  which  it  necessitates,  and  from  the  state  of  gene- 
ral irritation  which  it  gives  rise  to. 

If  the  means  we  have  just  mentioned  should  fail  in  arresting  the 
haemorrhage  ; if,  especially,  the  flow  of  blood,  by  its  quantity  or  dura- 
tion, exposes  the  life  of  the  patient  to  imminent  danger,  we  should 
seek  to  draw  towards  some  other  point  the  fluxionary  movement 
and  the  haemorrhagic  effort  directed  towards  the  uterus;  it  would 
be  well,  at  the  same  time,  to  overcome,  as  far  as  possible,  the 
spasms  upon  the  periphery  of  the  body,  which  keep  up  the  concen- 
tration of  vital  movement  towards  the  gestative  organ,  and,  in  certain 
cases,  to  act  directly  and  immediately  upon  the  vessels  which  throw 
off  the  blood,  by  determining  their  shrinking  and  constriction.  We 
can  fulfil  these  different  indications  by  means  of  re  vel  lents,  antispas- 
modics,  narcotics  and  astringents;  amongst  the  revel  lents,  bleeding 
ought,  with  good  reason,  to  be  placed  in  the  first  rank,  especially  in 
essential  active  metrorrhagia,  and  in  that  which  is  accidental  or 
which  depends  upon  a general  condition  of  the  constitution.  The 
bleedings,  which  in  these  cases  ought  to  be  made  from  the  arm, 
should  always  be  of  small  amount,  a palette  more  or  less.  To  obtain 
a more  powerful  revulsive  effect,  we  might,  after  the  example  of 
Riverius,  allow  the  blood  to  flow  little  by  little  only,  and  at  several 
different  times,  by  occasionally  keeping  the  finger  upon  the  orifice 
in  the  vein.  Where  bleeding  from  the  arm  appears  difficult,  as  often 
happens  in  women,  we  might  substitute  for  it  either  the  repeated 
application  of  three  or  four  leeches  to  the  anterior  and  upper  surface 
of  the  fore-arm,  or  beneath  the  mammae,  or,  as  Sennertns  advises,  and 
as  is  frequently  done  in  Italy,  by  practising  bleedings  from  the  hand 
in  the  vena  salvatella  or  cephalica.  It  would  likewise  be  well  to 


492 


METRORRHAGIA. 


determine  a powerful  revulsive  effect,  by  applying  cups  or  a sina- 
pism between  the  shoulders ; in  this  position  we  should  not  have  to 
fear  the  inconveniences  that  are  charged,  of  increasing  the  haemor- 
rhage when  they  are  applied  to  the  breasts,  as  Hippocrates  recom- 
mends, (Aphoris.  50,  sect,  v.),  or  underneath  the  same  organs,  accord- 
ing to  the  precept  of  Galen.  The  ventouses  monstres  of  Dr.  Junot, 
applied  to  both  the  arms,  produce  a very  energetic  revulsion,  which, 
in  our  opinion,  should  render  their  employment  preferable  to  the 
warm  manuluvia  recommended  by  F.  Hoffman  ( De  hsemorrhagiis 
gen.  orig.  et  curat.,  1697  ; Lordat),  ( Traite  des  Hsemorrhagi.es,  1806; 
Desormeaux),  (Diet,  de  med.  t.  xiv);  it  is  well  understood  that 
these  different  revellents,  applied  to  the  superior  extremities  or  any 
point  whatever  of  the  chest,  ought  to  be  rejected,  or,  at  least,  em- 
ployed with  the  greatest  circumspection,  where  the  lungs  are  feeble 
and  disposed  to  become  the  seat  of  a sanguine  congestion  ; vomiting, 
provoked  by  ipecacuanha,  and  recommended  by  Hippocrates,  Stoll, 
Fincke,  Cullen,  Alphonse  Leroy,  Gardien,  Osborn  and  some  others, 
produces  a kind  of  perturbation  and  derivation  which  may  be  advan- 
tageous in  some  cases,  principally  where  the  metrorrhagia  is  con- 
nected with  some  gastric  disorder;  but  as  it  is  impossible  clearly  to 
determine  the  circumstances  under  which  emetics  ought  to  be  pre- 
scribed, we  think  that  they  should  not  be  resorted  to  except  with  great 
prudence  and  discrimination.  In  case  the  metrorrhagia  depended  upon 
sympathetic  reaction  with  some  disorder  of  a distant  organ,  the  first 
indication  would  be  to  attend  to  that  disorder;  but  we  ought  first  to 
resort  to  the  employment  of  narcotics  and  antispasmodics,*  should 
the  uterine  haemorrhage  have  succeeded  some  vivid  emotion  or 
shock  of  the  nervous  system. 

To  the  employment  of  the  means  we  have  just  pointed  out,  should 
be  added,  at  the  same  time,  in  obstinate  cases,  the  use  of  astringents, 
amongst  others  injections  and  decoctions  of  the  bark  of  the  pomegra- 
nate, or  oak,  of  tormentil,  or  of  bistort,  and  particularly  that  of  rhatany 
root,  solutions  of  alum,  and,  also,  cold  drinks,  acidulated  with  the 
aqua  Rabelliana.  In  cases  where  chronic  haemorrhages  had  resisted 
the  operation  of  a variety  of  remedies,  we  have  always  employed 
with  advantage  the  following  potion,  taken  in  tablespoonful  doses, 
every  half  hour : viz.,  take  of  orange-flower  water,  eight  ounces;  ex- 
tract of  rhatany,  two  drachms ; syrup  of  comfrey,  two  ounces  ; aqua 
Rabelliana, thirty  drops;  Rousseau’s  laudanum,  twenty-five  drops. 

[I  beg  leave  to  take  this  occasion  for  the  purpose  of  recommending  the 
trial,  in  some  perverse  cases  of  metrorrhagia,  of  a remedy  that  has  often 
proved  useful  in  my  hands;  and  where  the  use  of  astringents  is  indicated, 
as  in  the  instances  here  discussed  by  M.  Colombat,  I should  make  use  ot  it 
with  no  little  confidence.  The  remedy  in  question  is  a decoction  of  the 

* It  is  in  the  form  of  enemata  that  antispasmodics  and  narcotics  have  always 
seemed  to  us  to  prove  most  efficacious,  especially  in  the  following  formula;  assafee- 
tida,  fifteen  grains,  suspended  in  the  yolk  of  an  egg:  flaxseed  mucilage. eight  ounces; 
Sydenham’s  laudanum,  thirty  drops ; tincture  of  castor,  twenty  drops,  for  an  enema  of 
half  the  common  size. 


METRORRHAGIA. 


493 


roots  of  the  common  black  currant,  ripe,  and  the  roots  of  the  dewberry.  A 
handful  of  each  of  these  articles  is  to  be  boiled  in  two  quarts  of  water,  and 
after  straining  the  liquor,  the  patient  should  take  half  a cupful  occasionally 
for  a dose.  The  draught  is  by  no  means  disgusting,  and  I venture  to  say 
that  the  effect  of  the  administration  has  often  been  a very  sensible  diminu- 
tion of  the  discharge.  I should  deem  such  a formula  very  useful  in  country 
places,  where  every  facility  cannot  be  enjoyed  in  varying  the  more  scien- 
tific prescriptions  repeatedly,  upon  the  failure  of  such  as  may  have  been 
tried  without  success. — M.] 

The  drinking  of  large  quantities  of  iced  water,  advised  by  Hoff- 
man and  Leake;  very  cold  enemata  of  the  same  fluid,  which  Bezold 
speaks  of  having  seen  used  successfully ; and,  finally,  cold  hip-baths, 
the  uterine  injections  employed  by  Prosper  Alpinus;  the  application  of 
compresses  wet  with  iced  water,  with  vinegar  and  water,  or  with 
vinegar,  to  the  vulva,  thighs,  loins  and  hypogastrium,  can  be  justifia- 
ble only  by  a terrific  haemorrhage,  and  should  never  be  used  except 
in  despair  of  all  else,  in  evidenti  morbis  pericvlo . 

In  metrorrhagia  primarily  passive , or  assuming  this  character 
after  having  been  active , the  first  thing  to  be  done  is  to  try  to 
restore  the  strength  of  the  patient  by  suitable  regimen,  and  by  the 
employment  of  various  tonic  substances.  To  attain  this  end,  we 
should  advise  some;  kind  of  food  which  is  nourishing  without  being 
stimulant,  amongst  others,  roast  meats,  jellies,  farinaceous  substances, 
and  the  flesh  of  young  animals,  and  certain  fish.  Amongst  the 
tonic  medicines,  should  be  placed  in  the  first  rank  the  ferruginous 
preparations,  especially  the  subcarbonate  of  iron  administered  in 
pilular  form;  the  dose,  which  at  first  should  not  exceed  three  or 
four  grains  twice  a day,  to  be  gradually  increased.  We  may  also 
employ  with  benefit  the  ferruginous  mineral  waters,  the  decoctions  of 
catechu  or  kino,  extract  of  cinchona,  or  of  columbo,  and  diascordum; 
finally,  we  should  put  in  requisition  all  the  resources  of  hygieine,  and 
with  the  view  of  preparing  the  constitution  for  the  cessation  of  a dis- 
charge which  has  become  in  some  sort  necessary  to  it,  we  should 
practise  small  revulsive  bleedings  of  from  half  a palette  to  two  palettes 
at  most.  When,  by  its  excessive  quantity  or  protraction,  the  haemor- 
rhage has  induced  a state  of  debility  which  favours  the  relaxation  of 
the  mouths  of  the  exhalent  vessels,  and,  consequently,  the  effusion  of 
the  sanguine  fluid,  it  sometimes  becomes  necessary  to  sustain  the  vital 
forces  in  order  that  the  uterine  fibres  and  the  walls  of  the  vessels  may 
recover  their  power  of  contraction;  for  this  purpose,  we  might  pre- 
scribe, from  time  to  time,  a spoonful  of  generous  wine,  rendered 
aromatic  with  a few  drops  of  essence  of  canella;  by  this  means,  we 
arrested,  as  if  by  magic,  a ha3morrhage  which  had  lasted  nearly  a 
month,  in  the  person  of  the  Baroness  of  Car  * * *,  authoress  of  seve- 
ral charming  literary  productions. 

Guided  by  the  special  action  of  ergot  on  the  uterus,  and  even  on 
the  general  circulation,  MM.  Sparjani,  Pignana,  Cabini,  Negri,  Reca- 
mier,  Duparcque,  Trousseau  and  some  other  writers,  have  recom- 


494 


METRORRHAGIA. 


mended  this  substance  in  doses  of  from  five  to  fifteen  grains,  repeated 
two  or  three  times  in  the  twenty-four  hours.  Lastly,  in  haemorrhages 
of  long  duration,  M.  Vedekin  has  proposed  savine,  whose  action, 
however,  we  fear,  would  be  too  energetic  and  stimulating,  though 
Doctor  Sauter  speaks  of  having  used  it  with  the  greatest  success. 

To  prevent  the  return  of  the  haemorrhage,  we  should  remove,  as 
far  as  it  may  be  possible,  the  causes  which  have  given  rise  to  it,  and 
direct,  at  the  same  time,  light  food,  of  easy  digestion.  Hoffman 
recommended  asses’  milk,  diluted  with  Seltzer  water,  chiefly  for 
women  of  very  delicate  and  sensitive  constitutions,  who  are  more 
liable  than  others  to  uterine  haemorrhages.  The  patient,  who  should 
take  moderate  exercise  in  the  intervals  of  each  menstrual  period,  must 
remain  in  a state  of  repose  at  their  approach  and  during  their  pre- 
sence. A visit  to  the  country  should  be  recommended;  she  ought 
to  retire  at  an  early  hour,  rise  betimes  in  the  morning,  and  avoid 
all  vivid  emotions,  and  especially  the  use  of  coitus  and  all  circum- 
stances capable  of  giving  rise  to  erotic  desires.  It  will  be  well,  like- 
wise, to  institute  small  revulsive  bleedings  from  the  arm,  especially 
a few  days  before  the  epoch  of  the  menses.  Revellents,  employed 
with  discrimination,  and  particularly  the  wearing  of  a flannel  chemise 
next  to  the  skin,  will  also  be  useful  in  the  majority  of  cases. 

In  passive  metrorrhagia,  we  should  recommend  a diet  which  is 
succulent  and  tonic  without  being  stimulating,  and  at  the  same  time 
the  use  of  rough  wines,  and  of  beer  rendered  medicinal  by  the  infu- 
sion of  bitter  plants.  Tonics,  in  particular  the  preparations  of  iron, 
ferruginous  waters,  river  and  sea  bathing,  tonic  and  astringent  douches 
and  injections  into  the  vagina ; douches  of  the  same  kind  to  the  lum- 
bar and  hypogastric  regions,  and,  finally,  aromatic  fumigations  will 
often  be  useful,  especially  if  local  debility  exists. 

The  treatment  of  sympathetic  and  symptomatic  haemorrhages  is 
the  same  as  that  of  the  diseases  upon  which  they  depend;  it  should 
be  modified,  however,  according  to  the  degree  of  curability  of  the 
principal  disease,  and  according  as  the  uterine  flow  is  connected  with 
an  incurable  local  lesion,  or  a serious  disorder  of  some  other  viscus. 

When  the  metrorrhagia  depends  upon  an  incurable  disease  of  the 
womb,  it  is  almost  always,  unless  it  be  excessive,  beneficial  to  the 
patient,  since  it  diminishes  engorgement  and  allays  pain  ; commonly 
when  the  sanguine  flux  is  arrested,  whether  spontaneously  or  by  the 
assistance  of  art,  the  symptoms  soon  become  aggravated  ; in  cases  of 
this  kind,  it  is  therefore  quite  rational  to  respect  the  anormal  discharge, 
so  long  as  it  is  not  profuse  enough  to  endanger  life ; though  the 
haemorrhage  is  most  frequently  advantageous,  the  contrary  may  be 
the  case,  that,  is  to  say,  the  pain  and  other  symptoms  may  increase 
during  the  flow  of  blood,  which  then  becomes  the  sign  of  a new 
engorgement,  which  it  is  necessary  to  oppose  in  particular  by  re- 
vulsive bleedings.  Finally,  if  the  sympathetic  or  symptomatic  uterine 
haemorrhage  co-exist  with  a visceral  disease  liable  to  aggravation, 
and  to  become  dangerous  by  the  suppression  of  the  discharge  of 
blood,  we  ought  to  be  content  with  moderating  the  discharge,  and 


CHLOROSIS. 


495 


should  scrupulously  abstain  from  such  general  and  local  means  as 
might  entirely  suppress  it.  Nevertheless,  should  the  haemorrhage 
become  dangerous  and  threaten  the  life  of  the  patient,  all  other  con- 
siderations must  be  put  aside,  that  we  might  recur  as  soon  as  possi- 
ble to  the  most  powerful  measures,  and  especially  to  the  tampon, 
adjusted,  howeyer,  only  at  the  depth  of  an  inch  in  the  vagina  ; or  else 
to  the  use  of  simple  compression  applied  to  the  outside  of  the  vulva, 
and  maintained  by  the  hand  and  an  appropriate  bandage.  By  ob- 
serving these  precautions,  which  are  those  recommended  by  M.  Lis- 
franc,  we  need  no  longer  fear  irritating,  by  the  contact  of  the  appara- 
tus, the  altered  tissues  of  the  vagina  or  cervix  uteri,  whose  sensibility 
is  greatly  augmented  by  their  morbid  condition.  In  those  happily 
rare  cases  in  which  the  slightest  loss  of  blood  may  prove  mortal,  we 
must  plug  the  vagina  as  far  as  the  cervix,  by  means  of  a small  gauze 
bag  filled  with  common  ashes;  this  method,  which  is  the  more  effi- 
cacious because  it  acts  both  physically  and  chemically,  was  employed 
by  us,  with  entire  success,  in  an  apparently  desperate  case. 

We  conclude  by  observing  that  after  an  uterine  haemorrhage  has 
become  chronic,  it  is  imprudent  to  suppress  it  suddenly;  in  such 
cases,  we  should  always  commence  the  treatment  by  the  establish- 
ment of  one  or  two  issues  upon  the  inside  of  the  thigh,  in  order  to 
replace  or  reproduce  the  point,  of  irritation,  of  which  the  pelvis  has 
been  for  a long  time  the  seat. 

OF  CHLOROSIS  OR  GREEN  SICKNESS. 

There  is  generally  understood  by  the  term  chlorosis * * * § a set  of  symp- 
toms, the  principal  of  which  are,  a pale  greenish  tint,  and  puffi- 
ness of  the  face  ; loss  of  colour  and  dryness  of  the  skin,  coinciding 
with  general  debility  and  derangement  of  most  of  the  functions,  espe- 
cially those  of  the  circulation,  the  digestion  and  the  menstruation. 

Chlorosis  was  known  to  the  highest  antiquity,  for  it  is  mentioned  in 
the  works  of  Hippocrates,!  of  Galen, f of  Aetius,§  of  Paul  of  Egina,|| 
and  of  Avicenna.  IT  Authors  who  have  written  upon  the  disease 
have  assigned  different  names  to  it,  derived  from  the  symptoms  which 
accompany  it,  from  the  period  of  life  at  which  it  is  most  frequently  met 
with,  and  the  causes  which  they  supposed  gave  rise  to  it.  Taking 
the  chronological  order,  the  sage  of  Cos  calls  it  z^poa/u a;  Avicenna, 
illisis:  L.  Mercatus,/e5r?.s  alba  et  virginum  obstruction.es ; Baillou, 
fsedi  colores;  Roderic  a Castro  and  Daniel  Sennertus,  morbus  virgi- 
neus;  Ranchin  and  Varande,  chlorosis;  Ettmuller,  icteria  alba ; Sy- 
denham,  pallidi-colores;  J.  Langiusj/e^ns  amatoria;  Savage,  white 
jaundice;  Tissot,  opilations;  and  to  conclude,  nearly  all  the  authors  of 
the  present  time  designate  by  the  name  of  chlorosis , the  disorder 
which  we  are  now  considering. 

* From  the  Greek  xx«po'c,  green. 

flab.  de  morb.  virginum. 

t De  causis  symptom.,  lib.  i.  cap.  7. 

§ Tetrab.  iii.  serm.  1.  cap.  23.  et  tetrab.  iv.  serm.  4,  cap.10. 

U De  remed.  lib.  i. 

^ Canon  Med.,  lib.  iii.  fen.  21.  tract  iii. 


496 


CHLOROSIS. 


The  different  denominations  of  chlorosis  afford  ns  a kind  of  abridged 
history  of  the  disease,  and  prove,  at  the  same  time,  the  uncertainty 
which  has  always  prevailed  as  to  its  nature.  Though  ancient  and 
♦modern  authors  generally  agree  in  classing  chlorosis  amongst  asthenic 
diseases,  they  are  far  from  holding  the  same  opinion  as  to  its  location 
and  point  of  departure  in  some  diseased  organ.  As  it  would  require 
too  much  time  to  enter  upon  the  discussions  which  this  question  has 
raised,  we  shall  rest  content  with  recapitulating  the  principal  opinions 
and  grouping  together  those  which  are  identical  or  bear  some  analogy 
to  each  other. 

Some,  with  Galen,  Hoffman,  Gardien,  and  Hamilton,  consider 
chlorosis  to  be  the  result  of  an  adynamic  condition  of  the  digestive 
tube.  Others,  again,  see  in  this  disorder  merely  an  asthenia  of  the 
genital  organs,  and  a morbid  state  consecutive  to  suppression  of  the 
menses.  This  opinion  has  been  sustained  by  Forestus,  Roderic  a 
Castro,  Sennertus,  Mercatus,  Primrose,  Freind,  Cullen,  Tissot,  Pinel, 
Cabanis,  Desormeaux,  MM.  Roche,  Duges,  Blache,  and  a great 
number  of  others ; finally,  according  to  MM.  Boisseau,  Andral, 
Brachet,  of  Lyons,  Bouillaud,  Blaud,  Trousseau,  Bonnet,  and  Brueck, 
chlorosis  is  dependent  upon  asthenia  of  the  circulatory  system  and 
vicious  sanguification. 

We  do  not  believe  that  atony  of  the  digestive  organs  ought  to  be 
regarded  as  the  point  of  departure  of  chlorosis,  since  the  affection 
sometimes  precedes  the  derangement  of  the  digestive  function,  and 
since  even  the  stomach  sometimes  retains  its  normal  condition.  Be- 
sides, atony  of  the  gastro-intestinal  surface  always  co-exists  with 
that  of  other  important  functions.  An  asthenic  condition  of  the 
genital  organs,  with  amenorrhoca,  can,  with  no  better  reason,  be 
regarded  as  the  primary  sources  of  the  chlorotic  condition,  since  it 
may  make  its  appearance  in  well-regulated  girls,  who  do  not  cease 
to  be  so  throughout  the  disease  ; the  disease  has  likewise  been  ob- 
served in  women  perfectly  and  abundantly  menstruated,  in  pregnant 
women,  in  women  who  have  passed  the  critical  age,  in  children  of 
both  sexes,  and  finally  in  men,  instances  of  which  have  been  cited  by 
Sauvages,  Cabanis,  Chambon,  Franck,  Rahn,  Blayn,  Desormeaux, 
MM.  Roche,  Blaud,  Pujol,  of  Montpellier,  Tanquerel  des  Planches,* 
and  some  others.  While  it  is  allowable  to  infer,  from  these  facts, 
that  atony  of  the  organs  of  generation  is  not  the  primary  cause  of 
chlorosis,  we  still  acknowledge  that  the  womb  plays  some  part,  but 
only  a secondary  one,  in  the  disorder. 

The  theory  which  supposes  the  chlorotic  condition  to  depend 
upon  sanguine  asthenia,  producing  vicious  haematosis,  with  increase 
of  serum,  and  diminution  of  fibrous  colouring  matter  and  iron, 
does  not  state  the  true  nature  of  the  malady,  nor  does  it  indi- 
cate under  what  pathological  influence  the  disorders  of  the  circula- 
tion. digestion,  menstruation,  etc.,  make  their  appearance.  To  go 
back  to  the  probable  origin  of  the  disease,  and  explain  all  the  de- 
rangements of  the  disease,  which  together  constitute  chlorosis,  we 


* Lancette  Fran^aise,  18  July  ,1837. 


CHLOROSIS. 


497 


believe  the  primary  cause  of  the  affection  to  be  nothing  more  than 
a general  asthenia  of  the  nervous  system,  and  especially  of  the  nerves 
of  the  ganglionic  system,  or  of  organic  life  presiding  over  the  digest- 
ive, circulatory,  nutritive  and  genital  functions;  in  a word,  it  is  faulty 
innervation,  and  imperfect  action  of  the  trisplanchnic  nerve,  that 
give  rise  to  the  group  of  symptoms  constituting  chlorosis. 

[M.  Colombat,  in  this  paragraph,  has  properly  stated  that  in  chlorosis 
there  is  a vitiated  hsematosis,  which  has  a strong  influence  upon  the  malady; 
and  he  continues  his  remarks  upon  the  condition  of  the  blood,  in  his  two 
subsequent  paragraphs.  It  has  been  recently  shown  by  M.  Andral,  in  his 
work  on  Hsematosis,  that  the  constitution  of  1000  parts  of  healthy  blood  is 
as  follows,  namely,  water  790  parts,  albumen  80  parts,  blood-discs  127  parts, 
and  fibrine  3 parts  = 1000  ; and  he  shows  that,  in  plethora,  the  quantity  of 
the  solid  material  increases,  carrying  up  the  figure  for  the  disc  to  130  and 
even  to  150,  the  albumen  to  90  or  100,  and  reducing  the  figure  for  the  water 
in  proportion  to  the  rise  of  the  figures  for  the  solids.  In  the  opposite 
or  anaemic  state,  the  figure  for  water  may  rise  from  790  to  850,  or  even  to 
near  900,  while  the  disc  descends,  in  some  cases,  to  100,  to  60,  to  30,  and 
even  as  low  as  20. 

It  appears  to  me  to  be  very  clear  that  these  mutations  in  the  quantity  of  the 
constituents  of  the  blood,  cannot  exist  without  carrying  great  disorder  into  all 
the  varied  functions  of  life.  It  is  to  be  believed  that  the  power  of  the  brain, 
and  of  the  whole  cerebro-spinal  axis,  has  the  closest  relations  to  the  consti- 
tution of  the  blood,  and  the  momentum  or  rate  of  its  motion  in  the  vessels  of 
the  brain  and  the  system  at  large,  and  that  a healthful  and  natural  state  of 
that  fluid  will  produce  a due  and  exact  innervation,  while  a feeble,  watery 
and  unhealthy  blood  must  produce  a feeble,  irregular  and  imperfect  innerva- 
tion of  all  the  organs  of  the  body,  which,  under  such  circumstances,  not  only 
exert  their  secerning,  accretive,  and  development-powers  feebly  and  imper- 
fectly, but  by  the  very  fact  of  their  own  failure,  extend  the  derangements  to 
all  the  parts  on  which  they  can  exert  any  sympathetic  force.  But  the  deve- 
lopment of  the  Graafian  vesicle  is  one  among  the  transcendental  and  extraor- 
dinary powers  of  the  economy : one,  requiring  for  its  execution  the  attainment 
of  the  womanly  age  and  the  enjoyment  of  a sufficiently  good  health.  Hence, 
when  anaemia  is  considerable,  it  is  common  to  find  a failure  in  the  vesicular 
development,  an  amenorrhoea,  and  a consequent  exhibition  of  morbid  symp- 
toms, which  grow  cumulatively,  one  being  drawn  in  after  another  until  the 
whole  health  is  depraved  or  even  totally  lost. 

M.  Colombat  very  judiciously  refers  the  first  cause  of  chlorosis  to  a gene- 
ral asthenia  of  the  nervous  system,  but  principally  of  the  ganglionic  part  of 
it.  This  is  doubtless  true ; but  what  is  the  precise  point  at  which  dwells 
the  proximate  cause  of  the  disorder?  It  is,  I suppose,  seated  in  the  textures 
that  have  the  most  immediate  relation  to  the  hsematosis.  If  we  go  back  to 
first  principles,  we  shall  be  obliged  to  admit  that  the  fault  in  the  hsematosis 
32 


498 


CHLOROSIS. 


is  a fault  of  innervation,  but  yet  that  fault  must  be  traced  to  the  innervation 
not  of  an  abstract  constitution,  but  of  some  special  membrane  or  tissue, 
as  the  membrane  commune , as  Bichat  calls  it,  of  the  sanguiferous  apparatus. 
Here  is  the  seat  of  the  power  by  which  the  chyle  is  converted  into  blood. 
The  elaboration  of  the  blood  into  its  constituents  of  fibrine,  discs,  albumen, 
and  water,  depends  on  the  vital  force  of  the  lining  membrane  of  the  blood- 
vessels ; it  is  there  alone  that  the  fluid  poured  into  the  vascular  cyst,  from 
the  great  chyle  tube,  has  any  contact  or  connection  with  the  living  body. 
Have  we  not  a just  ground,  then,  to  believe  that  the  proximate  cause  of  the 
anaemic  malady  is  one  sealed  in  this  blood-vessel  tissue?  It  is  probably  true, 
as  M.  C.  observes,  that  an  inefficient  action  of  the  trisplanchnic  nerve  gives 
rise  to  the  symptoms  that  constitute  chlorosis;  and  yet  it  is  quite  as  probable 
that  disorders  in  the  vessels  themselves  may,  in  many  cases,  originate  the 
diseased  state  of  the  blood,  which,  as  I have  already  said,  implicates  such 
great  and  extensive  vices  of  the  innervation.  It  cannot  have  escaped  the 
most  careless  observation,  that  a violent  excitement  of  the  circulation  is 
rapidly  productive  of  vitiations  in  the  constitution  of  the  blood,  which,  in 
order  to  its  attaining  its  real  normal  character,  demands  a momentum  or  rate 
not  varying  greatly  from  some  seventy  pulsations  per  minute  for  the  adult. 
I regard  some  vitiation  of  the  constitution  of  the  blood  as  one  of  the  true 
elements  of  the  chlorotic  condition,  and  even  as  one  of  the  chief  of  the  pa- 
thological characteristics  of  the  malady.  It  is  true  that  a merely  watery  or 
hyperhvdrsemic  state  (as  M.  Colombat  calls  it)  of  that  fluid  will  not  consti- 
tute the  malady  in  question;  for  it  is  clear  that  the  symptoms  of  the  affection 
depend  upon  the  failure,  more  or  less  complete,  of  many  vital  functions, 
arising  from  the  imperfect  extrication  of  the  nerve  power  of  the  whole  cerebro- 
spinal system,  including  the  ganglionic  apparatus.  These  derangements  will 
exhibit  themselves  in  disordered  respiration,  circulation,  secretion,  digestion 
and  nutritious  absorption ; all  of  which  must  receive  a due  share  of  regard  in 
making  out  a method  of  treatment.  Among  the  disordered  secretions,  those 
of  the  reproductive  apparatus  are  not  the  first  in  order  of  importance,  and 
are  generally  the  last  to  resume  their  healthful  rate  and  character;  a return  to 
which  is  the  sign,  rather  than  the  cause,  of  restoration  to  full  and  vigorous 
health. 

From  this  I deduce  the  inference  that,  in  chlorosis,  one  of  the  great  desi- 
derata should  be  to  give  to  the  sanguine  circulation  its  just  number  of  pulsa- 
tions, to  restore  to  the  vascular  membrane  its  healthful  metabolic  force,  and, 
by  re-establishing  the  normal  figures  for  the  several  constituents  of  the  blood, 
restore  to  the  constitution  all  its  powers  of  innervation  and  development.  The 
means  within  our  power,  for  the  attainment  of  this  end,  are  numerous  and 
energetic,  of  undoubted  efficacy,  and  requiring  only  to  be  understood  in 
order  to  render  the  intervention  of  the  physician  as  useful  in  these  myste- 
rious and  hitherto  misunderstood  affections,  as  are  the  lancet  in  the  treatment 
of  croup  or  pleurisy,  or  the  Peruvian  bark  in  the  cure  of  intermittents. — M.] 


CHLOROSIS. 


499 


The  experiments  recently  made  by  M.  Dupuy,*  member  of  the 
Academy,  militate  in  favour  of  the  opinion  we  have  just  expressed, 
and  seem  to  prove  positively,  that  chlorosis  is  a nervous  affection, 
inducing  secondarily  excess  of  serous  blood,  a sort  of  aqueous  hsema- 
tosis,  which  might  be  designated  by  the  term  hyper  hy  dr  semi  a.  t This 
opinion,  it  seems  to  us,  explains  not  merely  the  various  derangements 
of  the  circulation  and  imperfect  performance  of  other  functions,  but 
is  also  in  perfect  harmony  with  the  mode  of  development,  the  pro- 
gress of  the  symptoms,  and  the  nature  of  all  the  consecutive  pheno- 
mena. We  ought  to  say,  however,  then,  as  chlorosis  is  confined 
almost  exclusively  to  the  female,  and,  moreover,  as  the  uterus  is  de- 
ranged, in  the  majority  of  cases,  it  seems  very  probable  that  a diseased 
state  of  that  organ  may  be  the  most  common  point  of  departure  of 
the  vicious  innervation  of  the  organism  which  constitutes  the  chlo- 
rotic disorder. 

Though  chemistry  has  revealed  to  us  the  presence  of  iron  in  the 
blood, X and  though  this  element  seems  to  exist  in  smaller  quantity 
in  the  blood  of  chlorotic  persons,  we  cannot  admit,  with  M.  Pujol, § 
that  the  affection  under  consideration  is  the  result  of  a deferrugina- 
tion  of  the  sanguine  fluid ; even  if  a want  of  the  iron  were  found 
to  be  the  material  condition  of  chlorotic  blood,  which  is  far  from  being 
proved,  it  would  still  be  necessary  to  seek  out  the  primary  causes,  and 
ascertain  the  source  of  this  change. 

The  predisposing  causes  of  chlorosis,  which  we  prefer  to  call  hy- 
perhydrsemia , are  numerous  and  various.  Some  of  them  are  gene- 
ral, and  others  peculiar  to  individuals.  Amongst  the  former,  we 
rank  the  female  sex  ; the  age  of  puberty ; hereditary  predisposition  ; 
rapid  and  premature  growth ; a feeble,  melancholic  constitution ; a 
lymphatic,  scrofulous  or  nervous  temperament ; the  privation  of 
the  physical  enjoyments  of  love,  or  their  abuse  ; the  state  of  widow- 
hood ; onanism  ; sudden  and  continued  suppression  of  the  menstruae, 
and  their  too  great  abundance;  frequent  haemorrhages,  and  finally, 
any  circumstances  which  may  interfere  with  a proper  innervation, 
as  for  example,  depressing  moral  emotions,  disappointments,  grief, 
sadness,  captivity,  and  the  melancholy  which  accompanies  unfortu- 
nate love ; 

Palleat  omnis  amans,  color  hie  est  aptus  amanti,  (Ovid.) 

The  general  causes  of  chlorosis  are  living  in  low,  damp,  and  cold 

*z  At  the  meeting,  held  October  31,  1837,  M.  Dupuy  communicated  to  the  Academy 
of  Medicine  that,  in  experiments  which  he  has  made  upon  horses,  the  division  of  the 
pneumogastric  nerve  always  enabled  him  to  observe  a progressive  diminution  of  the 
fibrine  of  the  blood,  during  the  few  weeks  that  the  animals  survived  the  operation. 

j-  We  just  now  observe,  in  Mess.  L.  Delaberge  and  Monnerefs  excellent  compen- 
dium, that  Doctor  Copland,  (Diet,  of  Prad.  Med.,  p.  317,)  also  regards  chlorosis  as 
the  result  of  asthenia  of  the  great  sympathetic  nerve. 

t M.  Barruel  conceived  the  ingenious  idea  of  making  a medal  from  the  iron 
which  might  be  collected  from  the  blood  of  a subject.  The  wife  of  one  of  the  cele- 
brated members  of  the  Ecole  de  Medecine  of  Paris,  wears  a ring  made  of  iron,  which 
was  extracted  from  blood  taken  from  her  husband,  during  the  course  of  a severe 
disease. 

§ Memoire  surla  chlorose ; Seance  de  Tacadetnie  de  Medecine,  31  Octobre,  1837. 


500 


CHLOROSIS. 


situations,  secluded  from  the  solar  rays,  as  in  quarries,  mines,  dun- 
geons, the  cellars  of  weavers,  in  low  workshops,  in  valleys  of  great 
depth,  which  are  shaded  by  wood,  and  in  the  sombre,  narrow,  and 
badly-ventilated  streets  of  large  cities.  Periods  of  famine,  continued 
use  of  heavy  indigestible  and  decomposed  food;  the  indulgence  in 
warm  aqueous  drinks,  or  in  the  excessive  use  of  vinegar,  of  green 
fruit,  and  all  crude  articles;  excessive  fatigue,  and  finally,  the  want 
of  exercise,  and  a sedentary,  lazy  and  voluptuous  mode  of  life,  are 
all  causes  of  the  nervous  asthenia,  which  gives  rise  to  the  derange- 
ment of  the  functions  constituting  chlorosis. 

Symptotns.  No  disease  inspires  more  tender  interest,  or  more 
touching  compassion,  than  the  state  of  paleness,  suffering  and  lan- 
guor, observed  in  a young  chlorotic  girl ; like  some  delicate  plant, 
deprived  of  the  beneficent  rays  of  the  sun,  she  is  a flower  which 
withers  and  droops  away  even  before  its  blossoming. 

The  approach  of  chlorosis  is  marked  by  a state  of  habitual  inertia 
and  melancholy ; the  patient  becomes  sombre  and  taciturn,  weeps 
without  cause,  and  sighs  involuntarily ; the  face  becomes  bloated ; 
the  expression  is,  as  it  were,  veiled  ; the  eyes  sad  and  languishing  ; 
the  eyelids,  which  are  swollen,  especially  in  the  morning,  are  encir- 
cled by  a blackish  areola,  strongly  contrasting  with  the  pearl-white 
colour  of  the  sclerotic  coat  and  the  pallor  of  the  lips ; the  skin,  parti- 
cularly of  the  extremities,  is  dry  and  cool ; the  pulse  frequent,  rather 
large  and  less  easily  compressed ; the  respiration  is  difficult ; diges- 
tion is  deranged ; the  alvine  dejections  become  white,  hard,  and 
sometimes  fluid  ; palpitations  and  fits  of  pandiculation  make  their 
appearance,  while  debility,  lassitude,  a desire  for  sleep,  or  rather  for 
repose,  as  well  as  the  whole  collection  of  symptoms,  augment  from 
day  to  day. 

The  patient  feels  frequent  inclination  to  make  deep  and  very 
strong  inspirations,  a symptom  which  is  excited  and  increased  by 
walking,  by  ascending,  by  slight  exercise  even,  and  finally  by  any 
mental  emotion.  Auscultation  generally  shows  the  impulse  of  the 
heart  to  be  stronger  than  natural.  The  carotid  arteries,  which  beat 
with  great  force,  are  the  seat  of  certain  anormal  sounds.  Sometimes 
we  have  a simple  bellows-sound,  or  a bellows-sound  & double  cou- 
rant ; at  other  times  it  is  a prolonged  vibration  and  a kind  of  hum- 
ming, described  by  M.  Bouillaud,  under  the  name  of  bruit  de  diabley 
from  its  resemblance  to  the  noise  produced  by  the  child’s  toy,  called 
the  dictble.  These  anormal  sounds,  which  are  symptomatic  of  chlo- 
rosis, and  which  become  more  evident  whenever  the  patient  makes 
any  exertion,  may  be  perfectly  heard  in  the  carotid  and  subclavian 
arteries,  and  sometimes  to  a less  degree  in  the  crurals.  By  com- 
pressing these  vessels  slightly,  taking  care  not  to  interrupt  the  circu- 
lation entirely,  we  are  enabled  to  hear  a kind  of  roar,  that  is  dis- 
agreeable to  the  ear.  If  the  patient  make  a lengthened  effort,  the 
sounds  suddenly  cease,  just  as  they  diminish  and  at  length  disappear 
in  the  cervical  arteries,  when  we  push  aside  the  larynx  from  near 
the  vessel  in  which  they  are  produced.  The  bruit  de  diable  to 


CHLOROSIS. 


501 


which  M.  Bouillaud*  first  called  the  attention  of  the  profession,  has 
been  explained  in  a very  ingenious  manner  by  Doctor  Beau,t  in  a 
memoir  inserted  in  the  Archives  Generates  de  Medecine , for  the  month 
of  February,  1838.  This  young  physician,  who  has  devoted  himself, 
with  the  utmost  zeal,  to  the  pursuit  of  science,  has  ascertained,  as  we 
ourselves  have  been  enabled  to  do,  likewise,  that  in  well-marked  chlo- 
rosis, that  is  to  say,  chlorosis  accompanied  by  arterial  sounds,  the 
volume  of  the  arteries  is  in  proportion  to  the  intensity  of  the  chloro- 
sis and  to  that  of  the  sound  ; the  size  of  the  vessels  diminishes  as  the 
disorder  is  approaching  to  a cure,  and  as  the  humming  noise  becomes 
less  sensible.  The  pulse  seems,  in  some  cases  of  chlorosis,  to  be 
small  because  it  is  soft  and  very  compressible.  It  is  soft,  because 
the  blood  is  watery  and  very  gently  impelled  by  the  action  of  the 
heart,  which  organ  is  not  duly  stimulated  ; it  is  full  and  well  deve- 
loped, however,  from  the  fact  that  the  sanguine  fluid  is  in  excessive 
quantity,  though  serous,  pale  and  deficient  in  fibrine.  It  is  the  aug- 
mentation of  the  serous  portion  of  the  blood  in  chlorotic  patients — it 
is  the  aqueous  plethora,  so  to  speak,  called  by  us  hyperhydrsemia — 
that  produces  all  the  plethoric  symptoms,  and  the  turgor  lympha- 
ticus  which  accompany  chlorosis. 

Blood  drawn  from  the  venous  system,  and  from  leech  bites,  is  pale 
and  aqueous  ; the  clot  is  soft  and  diffluent ; the  animal  heat  is  dimi- 
nished ; the  lips,  nose,  hands,  and  all  the  organs  situated  at  a dis- 
tance from  the  centre  of  circulation  are  cold  and  almost  icy;  the 
general  cellular  tissue  becomes  the  seat  of  a serous  turgescence, 
which  is  especially  observable  about  the  eyelids  and  face.  The 

* Recherches  sur  les  divers  bruits  du  coeur  et  des  arteres,  Journ.  hebd.,  t.ix.,p.  560, 
1833. 

j-  Doctor  Beau  supposes  the  bruit  de  diable,  observed  in  chlorosis,  to  be  caused  by 
the  shock  of  the  blood  against  the  arterial  walls,  and  the  want  of  due  proportion  be- 
tween the  exaggerated  sanguine  wave  and  the  size  of  the  vessel.  This  plethora, 
mi  generis,  which  seems  the  more  paradoxical,  because  it  is  acknowledged  that  there 
is  diminution  in  chlorosis  of  the  mas;?  of  blood  or  anaemia,  becomes  explicable, 
nevertheless,  when  we  reflect  that  most  of  the  chlorotic  sy  mptoms  belong  to  plethora, 
as  for  example  the  vertigo,  the  dazzling  of  the  eyes,  the  tinnitus  aurium,  the  cepha- 
lalgia, the  dyspnoea,  the  palpitations,  the  turgescence  of  the  face,  somnolence,  etc. 
The  superabundance  of  the  sanguine  fluid  coinciding  with  paleness,  languor,  arrest 
of  nutrition,  and  other  anaemic  symptoms,  is  nothing  more  than  an  increase  of  the 
serous  parts  of  the  blood,  which  fluid  is  impoverished  and  deprived  of  its  nutritive 
qualities.  If  we  admit  an  augmentation  of  the  mass  of  the  blood,  in  consequence 
of  the  excess  of  serosity  which  it  contains,  it  is  easy  to  understand  how,  from  the 
calibre  of  the  vessels  being  no  longer  in  due  proportion  to  the  volume  of  fluid  which 
passes  through  them,  there  must  result  a shock  and  friction  against  the  walls  of  the 
arteries,  which  give  rise  to  the  different  sounds  symptomatic  of  chlorosis.  The  idea 
of  a serous  plethora,  which  we  have  denominated  by  the  term  hy perky  dr aemia,  was 
maintained  by  Berner,  {de plethora  cum  cacohymid  complicatd,)  by  Gcelicke,  ( de  caco- 
hymid plethorse  pedisequd,)  and  by  Buchner,  (de  crebiore  sanguinis  missione  fecunda 
plethorae  getiitrice.)  M.  Beau  also  quotes  a passage  from  Boerhaave,  (de  morb.  ner- 
vorum, t.  i.,  p.  158,)  which  proves,  that  that  illustrious  physician  regarded  chlorosis 
as  the  result  of  a superabundance  of  serous  blood.  “ The  fluids  are  in  excess  over 
the  solids,  and  their  motion  is  retarded,  because  the  mass  to  be  moved  is  augmented 
while  the  moving  force  remains  the  same.  The  body  soon  becomes  inactive ; the 
young  girl  becomes  swelled,  and  grows  pale  ; for,  to  speak  truly,  she  does  not  lose  the 
red  portion  of  her  blood,  but  acquires  more  of  the  white  than  is  necessary,  in  propor- 
tion to  the  red.” 


502 


CHLOROSIS. 


inferior  extremities,  particularly  the  ankles,  become  oedematous,  a 
condition  which  is  most  marked  towards  evening,  and  which,  accord- 
ing to  Gardien,  differs  from  that  of  common  anasarca,  in  not  retain- 
ing the  impression  of  the  finger. 

As  the  disease  progresses,  the  functions  of  the  stomach  are  more 
and  more  deranged ; the  strangest  and  most  depraved  tastes  manifest 
themselves ; the  patients  prefer  the  most  sapid  substances,  such  as 
salt,  vinegar,  green  fruits  ; they  often  seek,  with  avidity,  indigestible 
substances,  and  such  as  are  in  no  way  nutritive,  as  charcoal,  chalk, 
plaster,  earth,  ashes,  spiders,  flies,  and  other  equally  disgusting  in- 
sects. The  appetite  gradually  diminishes  until  complete  anorexia  is 
established ; at  other  times,  on  the  contrary,  it  is  increased  beyond 
measure,  while  the  ingestion  of  food  is  followed  by  a sensation  of 
weight  at  the  epigastrium,  by  malaise,  and  sometimes  by  vomiting. 
The  tongue  is  generally  large  and  covered  with  a mucous  coat ; acid 
regurgitations,  and  frequent  nausea  occur,  especially  in  the  morning  ; 
a feeling  of  heat  and  weight  in  the  epigastric  region,  and  sometimes 
nervous  pains  in  the  course  of  the  oesophagus,  and  extending  through 
to  the  shoulders,  make  their  appearance.  Finally,  the  patients  expe- 
rience alternations  of  constipation  and  watery  diarrhoea.  The  alvine 
dejections  are  white,  while  the  urine  small  in  quantity,  is  pale  and  lim- 
pid, as  in  all  the  nervous  affections. 

The  sexual  organs  are  commonly  affected  with  an  abundant  leu- 
corrhceal  discharge  ; most  generally  there  is  failure  or  suppression  of 
the  menstruse;  at  other  times  they  persist  and  last  longer  than  natural; 
but  far  from  alleviating  the  sufferings  of  the  patients,  the  return  of 
the  menses  is  accompanied  by  the  most  diverse  nervous  disorders,  by 
uterine  cholics,  by  pains  in  the  loins,  and  great  depression;  by  a 
kind  of  stupidity  even.  When  menstruation  continues,  the  secreted 
fluid,  which  is  pale  and  watery,  separates  upon  the  napkin,  into  two 
distinct  portions,  and  forms  spots,  which  lose  their  colour  by  drying. 
The  nervous  system  participates  in  the  general  languor  of  the  func- 
tions ; the  patient  is  sad,  melancholy  and  indifferent  to  all  enjoyments. 
She  seeks  solitude,  sighs  involuntarily,  and  weeps  without  cause  ; she 
is  often  tormented  by  sinister  ideas ; her  temper  is  capricious,  odd 
and  irascible ; for  her,  all  thought  of  happiness  is  gone,  and  in  her 
despair  she  often  speaks  of  suicide  ; finally,  the  night,  far  from  pro- 
curing repose,  brings  her  only  broken  slumbers  and  frightful  dreams. 

To  these  disorders  of  the  intellectual  and  sensitive  apparatus,  there 
are  sometimes  added  the  most  discordant  nervous  symptoms,  such  as 
tinnitus  aurium,  vertigo,  partial  loss  of  sight,  tremors  of  the  limbs, 
cephalic,  cervical  and  dental  neuralgia,  peculiar  palpitations  in  the 
epigastrium,  and,  in  some  rare  cases,  hysterical  symptoms  even. 

When  the  progress  of  the  disease  is  not  arrested,  the  symptoms 
become  more  and  more  aggravated  ; the  head  becomes  the  seat  of 
severe  pain,  felt  mostly  in  the  occiput;  the  skin  assumes  a greenish 
or  earthy  hue ; the  abdomen  is  hard  and  tumid ; thirst  arises ; the 
dyspnoea,  faintness  and  palpitations  are  increased ; diarrhoea,  as  well 
as  hectic  fever,  creep  in ; daily  exacerbations  occur,  and  the  emacia- 
tion makes  rapid  progress.  Finally,  incipient  general  infiltration, 


CHLOROSIS. 


503 


extreme  feebleness,  invincible  repugnance  to  all  kinds  of  exertion, 
alteration  of  the  features,  and  a pale,  violet  colour  of  the  lips,  fore- 
bode approaching  death,  which  comes  at  last  without  shock  and 
almost  without  pain,  surprising  the  patient  under  a complete  state  of 
marasmus.  We  shall  close  by  stating  that  the  duration  of  chlorosis 
has  no  fixed  limit,  but  that  when  properly  treated,  it  commonly  ter- 
minates by  a return  to  health  in  from  one  to  two  months.  Yet  of 
twenty-eight  patients  treated  by  M.  Bland,  of  Beaucaire,  one-third 
recovered  in  less  than  twenty  days,  and  a single  case  only  was  pro- 
tracted to  the  thirty-second.  {Revue  Med.,  t.  i.  p.  387,  1832.) 

Differential  Diagnosis.  Though  the  symptoms  of  chlorosis  are, 
generally  speaking,  well  marked,  the  diagnosis  of  the  disease  is  not 
devoid  of  all  sources  of  error  ; we  shall  proceed  to  mention  the  chief 
pathognomonic  characters  of  the  diseases  which,  from  the  paleness 
and  general  loss  of  colour  which  accompany  them,  bear  in  that 
respect  some  resemblance  to  chlorosis. 

Of  all  morbid  conditions,  anaemia  is  the  one  which  most  resembles 
chlorosis;  the  analogy  existing  between  these  two  affections  is  so 
great  that  M.  Andral,  {Anal.  Pathol .,  t.  i)  , regards  them  as  one  and 
the  same  disease ; amongst  the  symptoms  common  to  both,  are 
classed:  paleness  and  decoloration  of  the  skin,  conjunctiva,  lips  and 
buccal  mucous  membrane ; shrinking  and  disappearance  of  the  sub- 
cutaneous veins ; muscular  debility;  fainting  on  the  slightest  exer- 
cise ; oedematous  engorgements ; derangements  of  the  gastro-intestinal 
functions,  and  identical  auscultative  phenomena.  Although  these 
symptoms  exist  both  in  chlorosis  and  anaemia,  we  can  distinguish 
those  belonging  to  the  former  disorder,  from  thair  being  always  car- 
ried to  a higher  degree  and  accompanied  by  nervous  symptoms  so 
marked  as  to  form  one  of  the  essential  characters  of  the  malady. 
We  can  detect  differences  that  will  enable  us  to  form  a correct  diag- 
nosis by  a reference  to  the  causes  and  by  a consideration  of  the 
course  of  the  disease.  The  progress  of  chlorosis  is  generally  slow; 
it  occurs  almost  exclusively  in  women  at  the  epoch  of  puberty,  and 
often  takes  its  rise  without  known  cause  or  appreciable  lesion. 
Anaemia,  the  source  of  which  is  almost  always  easily  discernible, 
commences,  on  the  contrary,  rather  suddenly,  especially  when  it  suc- 
ceeds to  spontaneous  or  secondary  losses  of  blood.  Moreover,  it  is 
met  with  in  both  sexes,  and  at  any  age.  The  chemical  analysis  of 
the  blood  might  also  assist  in  clearing  up  the  diagnosis : in  chlorosis, 
there  is  superabundance  of  serous  blood,  whilst  in  anaemia  properly 
so  called,  which  is  a transient  condition,  we  have  simple  diminution  of 
the  mass  of  the  blood.  The  former  disease  causes  paleness,  because 
the  sanguine  fluid  itself  is  deprived  of  colour,  while  the  same  phe- 
nomenon occurs  in  the  latter  only  because  the  vessels  are  almost 
empty  and  in  some  sort  exsanguineous. 

[I  have  been  accustomed  to  confide,  in  a good  measure,  in  a mode  of  diag- 
nosis which  I beg  leave  here  to  suggest  as  an  useful  one. 

Every  instance  of  anaemia  is  not  discoverable  always  upon  inspection  of 
the  tint  of  the  skin,  nor  upon  a survey  of  the  stale  of  the  patient  as  to  her 


504 


CHLOROSIS. 


embonpoint,  since,  in  some  anaemic  individuals,  the  cheek  and  lips  retain 
a considerable  degree  of  freshness  and  vivacity  of  colour  from  a natural  exu- 
berant vascularity  of  the  tissues  composing  them  ; and  there  are  not  a few 
anaemic  patients  who  even  grow  fat  during  the  malady.  Now  I should  in 
such  a case  test  the  state  of  the  lungs  by  asking  the  patient  to  make  several 
forced  inspirations,  in  order  to  discover  whether  the  capacity  of  the  lungs  for 
atmospheric  air  were  at  all  lessened  by  disease — and  should  she  appear  to  be 
able  to  inhale  fifty  or  sixty  cubic  inches  at  an  inspiration,  I should  have  a 
right  to  conclude  that  the  air-cells  of  the  lungs  were  free  from  pressure  or 
obstruction,  and  duly  expansible.  This  view  might  be  confirmed  by  per- 
cussion and  by  auscultation  of  the  chest.  Still  the  respiratory  difficulties 
remain  to  be  accounted  for,  especially  those  proceeding  from  every  muscular 
effort. 

I should  next  examine  the  frequency  of  the  pulse,  which,  in  a state  of  rest, 
might  be  sufficiently  quiet — as  at  70,  or  80,  or  90  beats  per  minute.  If 
now  the  patient  be  requested  to  walk  to  the  head  of  the  stairs,  and  return 
immediately  to  her  seat,  she  will,  if  anaemic,  be  found  to  have  the  pulse 
greatly  accelerated  and  beating  in  the  most  troublous  manner,  to  the  number 
of  120,  and  even  160  pulsations  per  minute,  while  her  respirations  may 
amount  to  40  and  even  60  per  minute.  This  fact  serves  to  disclose  the 
existence  of  the  anaemic  state,  which,  in  order  to  effect  any  powerful  innerva- 
tion as  exercise,  &c.,  requires  this  great  and  extraordinary  precipitation  in 
the  movements  of  the  heart. 

M.  Colombat  is  for  |he  most  part  so  correct  and  so  philosophical  in  his 
opinions,  that  it  might  be  considered  in  some  degree  unsafe  to  controvert  the 
inferences  which  he  makes,  and  always  surrounds  with  a strong  fortification 
of  arguments  and  well-selected  facts.  In  the  opinions  he  sets  forth  in  some 
of  the  preceding  paragraphs,  he  opposes  the  belief  that  an  altered  crasis  of  the 
blood  plays  a prime  important  part  in  the  maladies  grouped  under  the  head 
of  chlorosis,  and  that  anaemia  is  not  chlorosis — and  vice  versa.  But,  seeing 
that  no  case  of  chlorotic  disorder  can  well  exist  without  implicating  the  con- 
stitution of  the  blood,  I am  tempted  still  to  defend  an  opinion  that  regards 
that  fluid  as  greatly,  or  even  principally,  concerned  in  the  production  of  the 
malady. 

Nothing  is  truer  than  that  the  lining  membrane  of  the  sanguiferous  system 
is  liable  to  alterations  both  functional  and  physical.  These  alterations  are 
frequently  met  with  in  endocarditis,  and  it  is  a well-established  truth  that 
most  extensive  disease  of  the  membrane  commune  of  the  veins  is  met  with 
in  some  forms  of  puerperal  disease,  as  in  uterine  and  crural  phlebitis,  for 
example.  It  is  also  common  to  observe  the  membrane  commune  of  the 
great  arterial  trunks  presenting  the  signs  of  disease  in  the  form  of  engorge- 
ment thickening  and  red  inflammatory  injection. 

If,  then,  it  be  admitted  that  this  membrane  commune  be  capable  of  patho- 
logical modifications,  it  follows  that  all  the  life-powers  of  that  membrane 


CHLOROSIS. 


505 


must  also  be  liable  to  modifications.  Now,  what  are  these  life-powers — 
what  are  the  offices  or  functions  of  the  membrane  commune?  No  man  at 
the  present  day  can  propose  to  limit  those  powers  to  the  mere  physical 
agency  of  containing  the  blood!  On  the  contrary,  it  cannot  be  denied  that 
the  constitution  of  the  blood  is  some  how  intimately  connected  with,  and 
probably  in  immediate  dependence  upon  the  biological  state  of  this  very 
tissue.  All  the  products  of  the  nutritive  digestions,  after  passing  along  the 
lacteal  tubes  and  trunk,  are  poured  as  chyle,  ( not  as  blood,)  into  this  mem- 
brane, and  as  that  chyle  never  afterwards  touches  any  other  tissue,  it  is  clear 
that  in  the  contact  or  nerve-influences  of  that  tissue  resides  the  faculty  of 
converting  the  chyle  into  blood  and  of  converting  it  into  healthy  normal 
blood,  or  of  failing  so  to  convert  it;  whence  it  appears  that  the  sponta- 
neous and  pathological  modifications  of  the  blood,  as  to  its  crasis,  are  to  be 
sought  for  in  the  agency  of  this  very  membrane ; and  that,  whether  the 
mutation  be  into  the  state  of  plethora  or  into  that  of  anaemia. 

It  is  hardly  necessary  to  follow,  even  were  it  possible,  to  its  most  recon- 
dite and  hidden  depths  in  the  innervative  powers,  the  sole  unique  principle 
of  that  power  which  ought  to  give  to  the  body  in  health  a blood  consisting 
of  discs  147 — albumen  80 — fibrine  3,  and  water  790  = 1000  parts.  The 
anatomist  will  never,  perhaps,  succeed  in  unraveling  the  real  nerve  filaments 
that  endow  this  membrane  with  its  biological  forces;  but  should  he  attempt  it, 
he  will  doubtless  seek  to  trace  them  from  the  nerves  that  supply  the  various 
organs,  viscera  or  parts  throughout  which  the  membrane  is  distributed,  as  in 
the  spleen,  the  kidneys — in  the  stomach,  the  eye,  &c.,  wherever  a vessel 
runs  there  also  is  a nerve  fibril,  which  constitutes  not  only  a part  of  the 
organ,  but  also  a part  of  the  vessel  itself.  Wherefore,  every  organ  plays 
its  part  or  contributes  of  its  peculiar  influence  to  modify  the  vitality  of  its 
own  membrane  commune , and  thereby  to  modify  the  crasis  of  the  blood  while 
within  its  limits,  and  for  the  time  a part  of  its  nature.  See,  therefore,  what 
an  immense,  and  what  a varied  influence  is  that  the  blood  is  subject  to  as  it 
courses  among  the  tissues,  of  which  it  is  always  the  bond  that  unites  them  to 
the  organs  with  which  they  stand  connected  throughout  the  entire  economy. 

These  observations,  which  are  offered  in  brief,  may  suffice  to  show  why 
I cannot  accede  to  M.  Colombat’s  views  as  to  the  trifling  nature  of  the  role 
played  by  the  fluid  in  question  in  the  chlorotic  affections.  They  show  that 
(supposing  my  opinion  well  founded)  the  blood  may  be  greatly  in  fault  in 
these  cases,  and  it  must  be  quite  unnecessary  to  advance  arguments  to  prove 
that  with  a weakened,  dilute,  pale,  ill-animalized  blood,  we  must  look  for 
all  the  results  of  that  feeble  innervation  which  attends  the  presence  of  a 
weak  blood  in  the  vessels. 

There  can  be  no  sound  normal  healthful  innervation  without  a normal  equa- 
ble lateral  pressure  of  a healthy  blood.  Muscular  weakness  is  one  of  the  first 
manifestations  of  its  presence,  and  organic  or  visceral  debility  follows  in  rapid 
succession;  development  goes  on  slowly,  or  reluctantly  and  imperceptibly — < 


506 


CHLOROSIS. 


all  the  powers  of  the  economy  are  devoted,  under  such  circumstances,  to 
carry  on  the  more  important  actions  in  the  scheme  of  life,  while  the  lesser 
ones,  the  outposts,  are  overlooked  or  abandoned. 

What  more  need  I say — the  travail  ovarique  is  suspended ; no  more 
development  of  Graafian  vesicles;  one  viscus  after  another  becomes  involved 
in  disease,  and  the  patient  falls,  at  length,  the  victim  of  a malady  whose 
prime  seat  and  throne  were  in  the  membrane  commune  of  the  common  vas- 
cular sac  which  contains  all  the  blood  of  the  body. — M.] 

Jaundice  may  readily  be  distinguished  from  chlorosis,  by  the  yel- 
low colour  of  the  skin  and  by  the  nature  of  the  stools  and  urine ; by 
the  yellow  tint  of  the  sclerotic  coat  of  the  eye,  which  is  always  pearl- 
white  in  chlorosis,  and  finally,  by  the  absence  of  nervous  symptoms, 
of  palpitations,  and  particularly  of  anormal  sounds  in  the  arteries. 
We  may  avoid  mistaking  anasarca  for  the  affection  under  considera- 
tion, by  recollecting  that  the  cedematous  turgescence,  observed  in  the 
feet  and  legs,  and  sometimes  over  the  whole  surface  of  the  body,  is 
but  momentary  in  chlorosis,  and  that  though  observable  in  the  even- 
ing, it  disappears  in  the  course  of  the  night.  In  addition,  the  oedema- 
tous  swelling,  the  turgor  chloroticus , does  not  retain  the  impression 
of  the  fingers  as  does  anasarca,  unless  the  disease  has  reached  a very 
advanced  stage.  The  paleness,  the  dyspnoea,  the  palpitations,  the 
anormal  sounds  in  the  heart  and  arteries,  the  dizziness,  and  the  oede- 
matous  enlargement  of  the  limbs  which  we  meet  with  in  chlorosis, 
are  so  many  symptoms  of  organic  disease  of  the  heart.  In  this  con- 
dition, a mistake  may  have  serious  consequences,  for  the  treatment 
is  essentially  different.  Nevertheless,  the  appearance  and  sudden 
cessation  of  the  phenomena,  especially  of  the  anormal  sounds  of  the 
heart,  and  the  symptoms  of  cerebral  congestion  occurring  at  intervals, 
will  prevent  our  believing  in  the  existence  of  a permanent  organic 
lesion.  Moreover,  the  connection  of  the  symptoms,  the  age,  sex  and 
temperament  of  the  patient,  the  character  of  the  pulse,  the  march  of 
the  disease,  and  finally,  the  amelioration  which  follows  the  use  of 
martial  preparations  and  tonics,  will  suffice,  in  the  greater  number  of 
cases,  to  establish  a correct,  diagnosis.  It  is  well,  furthermore,  to 
recollect,  that  in  diseases  of  the  heart,  the  skin  is  less  altered,  that  the 
cheeks  generally  retain  their  colour,  that  the  face  is  sometimes  tume- 
fied, and,  finally,  that  the  lips  are  livid  and  swollen,  which  is  not  the 
case  in  chlorosis.  We  deem  it  useless  to  speak  of  the  differential 
diagnosis  of  this  disease  from  degeneration  and  chronic  affections  of 
the  stomach,  from  gastritis,  tympanitis,  intestinal  irritation,  etc.,  which 
often  occasion  paleness,  bearing  some  resemblance  to  that  which  fol- 
lows the  affection  forming  the  subject  of  our  chapter.  We  shall 
likewise  pass  by  in  silence  the  different  cancerous  and  tubercular 
degenerations  which,  at  a certain  period  of  their  progress,  have  as 
one  of  their  symptoms  a yellow  straw  colour.  All  these  diseases 
reveal  themselves  to  the  observe^’  by  their  pathological  localization, 
and  they  exhibit  distinctive  characters  and  corroborative  circum- 
stances, which  may  prevent  us  fr.om  confounding  them  with  the 
affection  now  under  consideration. 


CHLOROSIS. 


507 


The  prognosis  of  chlorosis,  when  the  attack  is  simple  and  of  recent 
date,  is  favourable  ; it  is  not  at  all  dangerous  in  itself,  and  often  dis- 
appears upon  a mere  change  of  air  and  regimen.  When  the  patient 
can  be  placed  under  favourable  hygieinic  and  moral  conditions,  it  is 
surprising  to  see  the  rapidity  of  the  cure.  Under  the  influence  of  a 
well-directed  therapia,  we  often  see  a life,  which  seemed  about  to  be 
extinguished,  almost  instantaneously  reanimated.  But  when  the  dis- 
ease is  left  to  itself,  or  combated  by  irrational  treatment,  it  often 
becomes  complicated  with  organic  lesions  of  the  stomach,  heart, 
lungs,  liver,  spleen,  and  with  various  dropsical  affections,  which 
speedily  conduct  the  patient  to  the  tomb.  As  there  is  no  definite 
duration  for  the  periods  of  the  disease,  the  prognosis  can  be  based 
only  upon  the  length  of  the  attack,  and  the  nature  of  the  complica- 
tions. We  ought,  also,  to  take  into  account  the  constitution  of  the 
subject,  and  her  mode  of  life,  occupations,  and  hygieinic  circum- 
stances. Chlorosis,  appearing  after  the  establishment  of  menstrua- 
tion's more  unfavourable  than  when  it  occurs  in  a young  girl  not  yet 
regulated.  It  is  generally  believed,  that  chlorotic  women  are  almost 
always  sterile,  or  at  least  give  birth  to  feeble  and  sickly  children 
only,  but  we  think  that  this  opinion  is  correct  only  in  regard  to  per- 
sons in  whom  the  disease  presents  great  intensity,  and  when  it  has 
been  of  long  standing. 

The  treatment  of  chlorosis  includes  two  principal  indications to 
remove,  as  far  as  possible,  the  predisposing  causes  and  appreciable 
morbific  influences  which  have  produced  or  maintain  the  disease, 
and,  at  the  same  time,  to  resort  to  measures  calculated  to  impart 
energy  to  the  functions  of  nutrition  and  sanguification.  For  these 
reasons,  we  divide  the  treatment  into  the  hygieinic  and  pharmaceu- 
tical. 

Whatever  may  have  been  the  cause  that  has  brought  on  the  chlo- 
rosis, we  should  remove  the  patient  from  all  exposure  to  cold  and 
humidity ; she  should  breathe  a dry,  pure  and  moderately  warm  air, 
and  it  is  for  this  reason  that  spring  and  autumn  are  most  favourable 
to  the  cure  of  the  disease.  A dry,  breezy  situation,  in  a sunny 
exposure,  ought  to  be  recommended.  Clothes  which,  by  the  nature 
of  their  tissue,  slightly  irritate  the  skin,  are  to  be  preferred  to  any 
others.  Flannel  worn  next  to  the  skin,  and  especially  alcoholic  and 
aromatic  frictions  of  the  whole  surface  of  the  body  should  likewise 
be  proposed,  with  the  view  of  exciting  the  action  of  the  capillary 
vessels,  of  inviting  the  blood  into  them  and  promoting  perspiration. 
The  food  must  consist  of  roast  meats,  fresh  eggs,  farinaceous  vegeta- 
bles, ripe  fruits,  and  bitter  and  aromatic  plants,  for  example,  succory, 
and  celery.  As  a drink  during  meals,  we  may  employ  with  advan- 
tage a mixture  of  chalybeate  water,  with  Bordeaux,  or  still  better, 
with  Burgundy  wine,  which  contains  a large  quantity  of  astringent 
matter.*  Between  the  repasts  the  patient  may  allay  her  thirst  with 
some  refreshing,  slightly  acidulated  drink.  Nevertheless,  though  a 

* We  might  prepare  the  gaseous  eau  fcrree,  with  Doctor  Quenesville’s  powder. 
This  solution,  which  is  of  easy  administration,  is  generally  taken  by  the  patients 
with  pleasure. 


508 


CHLOROSIS. 


careful  regimen  ought  to  be  strictly  observed,  it  is  not  well  to  be  too 
exclusive;  if  we  meet  with  great  reluctance  in  giving  up  the  injurious 
articles  which  the  patients  desire,  it  would  be  necessary,  at  first,  to 
respect  their  longings,  however  strange  they  might  seem,  and  even 
to  satisfy  them,  unless  they  were  directed  to  substances  evidently 
hurtful.  We  should  always  commence  by  regulating  the  meals,  by 
forbidding  fruit,  salad  and  all  crude  articles ; we  ought,  moreover, 
to  consider  the  digestive  functions,  and  wholly  proscribe  nothing  but 
known  indigestible  articles. 

Whatever  be  the  aversion  to  exercise  felt  by  chlorotic  persons,  we 
ought  invariably  to  insist  upon  its  employment,  regulating  it,  how- 
ever, by  the  state  of  the  strength.  Should  the  muscular  debility  be 
so  great  as  to  prevent  the  patient  from  walking,  we  must  resort  to 
mixed  and  passive  exercises.  Riding  in  a carriage,  or  still  better,  on 
horseback,  especially  if  a man’s  saddle  is  used,  in  open  and  elevated 
places,  when  the  air  is  pure,  are  proper  modes  of  exercise,  particu- 
larly if  pleasant  conversation  can  be  added  to  the  charms  afforded 
by  diversity  of  views  and  landscapes.  Boating-excursions,  which 
exert  a favourable  effect  upon  ail  the  organs,  and  which  unite  to  all 
the  advantages  of  exercise,  that  of  being  agreeable  to  young  per- 
sons, and  of  producing  an  useful  stimulation  by  the  presence  of 
individuals  of  the  opposite  sex ; music,  which  occasions  a salutary 
excitation  in  lymphatic  persons,  and  finally,  sea-bathing,  and  swim- 
ming in  running  water,  are  different  hygieinic  means  which  it  is  well 
to  recommend  to  nervous,  sad,  melancholy  women,  and  to  those  of 
great  moral  sensibility.  Travelling  cannot  be  too  strongly  recom- 
mended to  persons  in  whom  the  disease  is  kept  up  by  acute  sorrow, 
or  by  any  moral  affection  whatsoever ; the  use  of  mineral  waters 
taken  at  the  springs,  offers,  in  this  respect,  incalculable  advantages, 
not  only  from  the  medicinal  action  of  the  waters  themselves,  but 
also,  because  the  patients  enjoy  at  such  places  the  various  charms  of 
a numerous  and  brilliant  society,  and  attractions  which  are  con- 
stantly changing.  The  springs,  which  have  been  most  strongly 
recommended,  are  those  of  Spa,  Plombieres,  Vichy,  and  Pyrmont. 

The  use  of  very  tight  corsets  ought  to  be  forbidden ; sleep  should 
not  be  protracted  beyond  eight  or  nine  hours,  and  care  must  be  taken 
that  the  patient’s  bed  be  neither  too  warm  nor  too  soft,  because 
such  beds  often  increase  the  feebleness  and  constipation  of  very 
sensitive  women,  especially  those  in  whom  the  chlorotic  state  has 
been  developed,  and  maintained  under  the  influence  of  disappointed 
love.  We  should  forbid  exciting  drinks,  the  use  of  wine,  and  highly 
nutritious  food  ; vivid  emotions  ; the  frequenting  of  balls  and  shows; 
the  reading  of  high-wrought  romances ; the  examination  of  lascivious 
pictures,  and  finally,  we  should,  as  far  as  possible,  suppress  all  cir- 
cumstances capable  of  disturbing  the  sensibility,  or  of  exciting  the 
passions  too  strongly.  It  is  in  such  cases  as  these  especially  that 
we  ought  to  insist  upon  sedative  drinks,  warm  baths,  and  especially 
upon  some  means  of  diversion  to  be  kept  in  constant  action. 

The  pharmaceutical  treatment  of  chlorosis,  whether  accompanied 
by  derangements  of  the  menstrual  flux  or  not,  consists  in  restoring 


CHLOROSIS. 


509 


ihe  tone  of  all  the  functions,  by  means  of  a tonic  and  excitant  medi- 
cation. Of  all  the  therapeutical  agents,  iron  is  the  one  which  should 
be  placed  in  the  first  rank,  on  account  of  its  constant  efficacy.  This 
metal,  regarded  with  good  reason  as  a specific  in  chlorosis,  has  been 
employed  alone,  and  associated  with  a number  of  other  remedies, 
such  as  the  extracts  of  succory,  parsley,  absinthium,  gentian,  blessed- 
thistle,  cinchona,  rhubarb,  etc.  It  has  also  been  prescribed  in  com- 
bination with  emmenagogue  substances,  as,  for  example,  saffron  and 
aloes,  etc.,  or  with  canella,  conserve  of  roses,  anise,  tartrate  of  potash, 
lemon-juice,  chocolate,  white  wine,  (and  vinum  ferri.)  Finally,  it 
has  been  ordered  infill  its  different  forms ; in  the  minutely  divided 
metallic  state,  in  the  state  of  oxide,  (gethiops  martial,)  in  the  state  of 
salt,  sulphate  of  iron,  (green  vitriol,)  tartrate  of  potash  and  iron, 
(boule  de  Nancy,)  and  subcarbonate  of  iron,  which  is  at  present 
preferred,  either  incorporated  with  syrup,  into  an  electuary,  or  admi- 
nistered in  the  form  of  pills,  of  pastilles,  of  powders,  etc.,  and  in  doses 
of  from  six  or  eight  grains  to  half  a drachm,  or  a drachm,  two  or  three 
times  a day.* 

Doctor  Blaud,  of  Beaucaire,  supposing  that  the  subcarbonate  of 
iron  does  not  exert  all  its  curative  properties,  unless  so  modified 
as  not  to  be  rejected  by  the  absorbent  orifices,  and  unless  given  in 
sufficient  doses,  has  proposed  the  following  formula  as  best  fulfilling 
these  two  essential  conditions.  R.  Sulphate  of  iron,  and  subcarbo- 
nate of  potash,  each  half  an  ounce  ; reduce  them  separately  to  a 
very  fine  powder;  then  mix  very  thoroughly,  little  by  little;  add  a 
sufficient  quantity  of  mucilage  of  gum  tragacanth  ; beat  strongly  in 
a mortar,  and  make  a mass  to  be  divided  into  forty-eight  boluses. 
“ There  results,  from  this  mixture,  a mutual  decomposition  of  the 
two  salts.  The  subcarbonate  of  iron  thus  formed,  being  in  a state 
of  extreme  division,  becomes  more  readily  absorbable,  while  at  the 
same  time  it  acquires  from  its  chemical  composition,  greater  activity. 
The  sulphate  of  potash,  which  is  also  present,  greatly  favours  its 
absorption  by  determining  its  movement  along  the  mucous  mem- 
brane of  the  digestive  tube  by  the  contraction  it  produces,  and  by 
exciting  the  lymphatic  absorbents  situated  upon  it.”t 

M.  Blaud  directs  a pill  to  be  taken  early  in  the  morning,  and  in  the 
evening  upon  retiring,  during  the  first  three  days.  On  the  fourth, 
fifth,  and  sixth  days,  he  adds  a pill  at  mid-day  ; the  seventh,  eighth, 
and  ninth  days,  two  pills  in  the  morning  and  two  in  the  evening ; 
the  tenth,  eleventh,  and  twelfth  days,  two  more  in  the  middle  of  the 
day  ; the  thirteenth,  fourteenth,  and  fifteenth  days,  three  pills  in  the 
morning  and  three  in  the  evening  ; the  sixteenth,  and  following  days, 
four  pills  three  times  a day.  He  continues  this  dose  long  enough  to 
dissipate  the  symptoms  of  the  disease,  and  then  returns  gradually  to 
the  smaller  doses,  as  at  the  commencement. 

* The  English  physicians,  particularly  Doctor  B.  Hutchinson,  have  found  great 
benefit  from  the  use  of  the  subcarbonate  of  iron,  carried  to  the  dose  of  from  one  to 
three  drachms  daily,  taken  at  three  different  periods.  Edinburgh  Journal,  vol.  18,  pp. 

321  and  411. 

f Mem.  sur  les  Malad.  Chlorotiques,  Revue  M6d.  t.  i.,  p.  337,  1834. 


510 


CHLOROSIS. 


Scarcely,  says  M.  Blaud,  is  the  remedy  introduced  into  the  eco- 
nomy, whatever  be  the  duration  and  violence  of  the  disease,  before 
a sensible  improvement  is  observed;  this  appears  sometimes  on  the 
second,  or  even  on  the  first  day  of  the  treatment,  after  years  of  suffer- 
ing, and  most  singular,  without  the  aid  of  any  auxiliary  treatment.  We 
have  but  to  note  a progressive,  and  generally  a rapid  amelioration, 
whose  course  nothing  suspends,  even  in  individuals  labouring  under 
cardialgia,  diarrhoea,  etc.,  symptoms  which  would  seem  to  contra- 
indicate all  tonic  medication.  At  first  a light  rosy  tint  appears  upon 
the  cutaneous  surface,  chiefly  upon  the  face,  and  the  eyes  assume  the 
lustre  which  they  had  lost.  At  the  same  tim%,  or  a little  later,  the 
symptoms  of  nervous  disturbance,  the  gastralgia,  which  nothing 
could  calm,  the  insomnia,  the  buzzing  in  the  ears,  the  cephalalgia, 
which  had  resisted  all  remedies,  sensibly  diminish,  and  before  long 
disappear.  The  respiration,  also,  becomes  freer,  the  pulse  less  fre- 
quent, the  palpitations  less  severe  and  more  rare,  the  infiltration  of 
the  limbs  is  dissipated,  the  muscular  force  is  re-established,  appetite 
returns,  the  moroseness  vanishes,  a feeling  of  general  comfort  suc- 
ceeds to  the  wearing  misery  which  rendered  the  life  of  the  patient 
so  deplorable,  and  all  the  organic  functions  soon  return,  as  if  by  a 
miracle,  to  their  normal  state. 

[The  author  appears  to  have  confined  himself  solely  to  the  recommenda- 
tion of  Blaud’s  pill,  as  a chalybeate  remedy  in  chlorosis ; and  perhaps 
that  preparation  does  in  fact  combine  all  the  activity  and  convenience  desira- 
ble in  any  ferruginous  formula.  Nevertheless,  as  not  a few  persons  are  to 
be  met  with,  who  appear  insuperably  opposed  to  the  use  of  pills,  and  as  his 
pills  are  of  ten  grains  weight  each,  it  is  highly  convenient  to  have  other 
formulae  that  may  suit  their  tastes  or  prejudices,  which,  in  medical  practice, 
ought,  to  a certain  extent,  to  be  respected.  M.  Raciborski,  in  his  ingenious 
and  most  valuable  work,  Be  la  Puberte , &c.,  gives  high  praise  to  the  com- 
binations of  the  oxyde  of  iron  with  weak  acids,  under  the  supposition  that 
they  most  readily  yield  their  place  to  the  new  combination  of  principles 
that  ought  to  take  place  in  the  stomach.  With  this  view,  he  recommends 
strongly  the  citrate  of  iron,  &c. 

I have  made  most  advantageous  use  of  a citrate  of  iron  conjoined  with  sul- 
phate of  quinia;  as  in  the  following  formula,  which  I subjoin  as  a very  con- 
venient and  successful  one,  in  the  disorders  dependent  upon  anaemia: 

Take  of  citrate  of  iron,  2 drachms; 

Sulphate  of  quinia,  £ drachm:  , 

Water,  1 fluid  ounce; 

Mix,  and  direct  from  20  to  30  drops  for  the  dose,  in  syrup  and  water. 

Agreeably  to  M.  R ’s  method,  I advise  the  patient  to  take  the  draughts 
after  each  meal,  within  half  an  hour  of  the  breakfast,  dinner  or  supper,  so 
that  it  may  be  carried  with  the  chyle  along  the  course  of  the  bowels. 

The  addition  of  the  quinia  to  the  ounce  of  water,  renders  the  citrate  and  the 
sulphate  perfectly  soluble,  as  does  also  the  addition  of  a few  drops  of  ammo- 


CHLOROSIS. 


511 


nia  to  a solution  of  the  citrate  alone ; without  some  such  addition,  a part  of 
the  citrate  of  iron  is  not  dissolved.  Vallet’s  mass  of  the  carbonate  of  iron  is 
also  worthy  of  much  confidence  ; it  is  a most  convenient  and  active  ferrugi- 
nous medicine.  Made  into  pills  of  two  to  five  grains  each,  it  is  found,  in 
numerous  instances,  to  remove,  with  great  rapidity,  the  disorders  of  the  cir- 
culation, connected  with  the  anaemic  and  chlorotic  states. 

M.  Raciborski  highly  recommends,  as  endowed  with  the  two  chief  desi- 
derata of  great  therapeutic  activity  and  absolute  insipidity,  a metallic  iron 
or  impalpable  powder.  It  is  prepared  by  heating  protoxyde  of  iron  in  a 
gun  barrel,  to  redness,  and  then  passing  through  it  a stream  of  hydrogen. 
In  the  process,  the  hydrogen  combines  with  the  oxygen  of  the  protoxyde  to 
form  water,  and  passes  off,  leaving  the  iron  reduced  to  a purely  metallic 
state,  and  impalpably  fine.  This  is  much  used  in  France,  in  the  form  of 
lozenges,  and  is  greatly  admired  for  its  curative  power. 

I have,  on  many  occasions,  directed  my  patients  to  purchase  one  or  two 
ounces  of  Vallet’s  mass,  and  to  take  a piece  as  large  as  a pea,  after  each 
meal.  This  may  be  done  with  persons  who  are  averse  to  the  use  of  pills, 
and  is  a means  of  saving  trouble,  and  even  of  avoiding  the  disgust  and  feel- 
ing of  constraint  apt  to  follow  the  prolonged  use  of  a regular  medical  formula. 
M.] 

The  dose,  to  which  the  subcarbonate  of  iron  should  be  gradually 
increased,  is  a drachm  daily,  but  it  is  very  important  not  to  stop  the 
treatment  suddenly,  just  when  a return  to  health  is  about  to  take 
place.  M.  Blaud  advises  a continuance  of  the  treatment  as  long  as 
may  be  necessary  to  dispel  the  symptoms,  and  he  considers  a gradual 
return  to  the  earlier  doses  as  very  important  in  establishing  the  cure. 
At  the  same  time  that  we  subject  the  patient  to  this  treatment,  we 
should  prescribe  for  her  drink,  during  meals,  either  the  natural  ferru- 
ginous waters,  as  Spa,  of  Passy,  or  of  Forges  water,  mixed  with  wine, 
etc.,  or  simply  water,  into  which  has  been  plunged  a piece  of  hot 
iron,  or  which  has  been  prepared  with  the  chalybeate  powder  of 
Dr.  Quenesville.*  To  increase  the  efficacy  of  this  treatment,  or  of 
any  other  of  the  same  kind,  it  will  be  well  to  prescribe,  at  the  same 
time,  alcoholic  frictions  over  the  whole  body,  and  the  use  of  some 
slightly  stimulating  tisan,  as  an  infusion  of  balm,  of  mugwort,  of 
hyssop,  of  lungwort  root,  etc. 

Other  tonics  might  likewise  be  added  to  the  iron,  such  as  tisan  of 
hops,  of  gentian,  of  the  lesser  centaury,  of  blessed  thistle,  etc. 

In  his  thesis,  No.  51,  1803,  M.  Ballard  speaks  of  having  derived 
good  effects  from  the  tan  of  the  oak  bark,  or  of  the  horse-chestnut. 
Tannin,  extolled  by  Dr.  Pezonni,  is  likewise  an  excellent  therapeutic 

* A gaseous  chalybeate  water  may  be  prepared  in  the  following  manner:  Take 
of  crystallized  sulphate  of  iron,  2 drachms;  white  sugar,  3 drachms;  pulverize  and 
make  into  twelve  powders.  Take  of  bicarbonate  of  soda,  2 drachms;  white  sugar,  3 
drachms;  pulverize,  and  divide  into  twelve  powders.  One  paper  of  each  of  these 
powders  is  dissolved  in  half  a glass  of  water;  then  the  two  portions  of  water  are 
mixed  and  swallowed  during  the  eifervescence. 


512 


CHLOROSIS. 


means  in  chlorosis ; it  may  be  administered  either  combined  with 
opium,  with  iron,  or  in  aqueous  or  vinous  decoction ; or  else,  which 
is  preferable,  in  the  pilular  form,  from  sixty  to  one  hundred  grains 
being  taken  in  the  twenty-four  hours,  at  different  times. 

Constipation,  a symptom  as  constant  as  it  is  troublesome,  must 
be  treated  by  enemata  and  laxatives.  Purgatives  might  also  be 
employed  with  the  same  end ; they  often  produce  a stimulation 
which  greatly  assists  the  cure.  Dr.  Hamilton,  who  regarded  consti- 
pation as  the  principal  cause  of  the  disease,  recommended  pills  of 
aloes  and  gamboge,  as  well  as  the  powder  and  the  tincture  of  jalap. 
Rhubarb,  in  doses  of  from  six  to  fifteen  grains,  taken  just  before 
eating,  seems  to  us  the  most  suitable  remedy,  from  its  tonic  and 
purgative  properties.  Drastics  should  be  resorted  to  with  great  re- 
serve, and  only  where  rhubarb  and  enemata  have  failed  to  relieve  the 
constipation.  They  should  be  rejected  in  toto  where  the  disease  is  far 
advanced,  or  complicated  with  a lesion  of  the  stomach,  liver  or  other 
viscera.  Emetics,  which  were  first  proposed  by  Mercatus,  physician 
to  Philip  II.,  King  of  Spain,  (Gynoeciorum,  sive  de  mulierum , etc., 
1554,)  may  be  appropriate  for  cases  in  which  the  disease  is  compli- 
cated with  some  gastric  disorder.  Baillou  ( de  virgin,  et  mulier.  morb ., 
1643,)  relates  that  all  the  remedies  employed  for  the  cure  of  the 
daughter  of  a goldsmith,  aged  eighteen  years,  and  affected  with  chlo- 
rosis, proved  unsuccessful:  but  he  adds  that  the  young  patient  was 
thrown  from  a carriage,  which  caused  her  great  fright,  and  brought 
on  a very  abundant  vomiting  of  bile  : from  that  moment  her  appetite 
returned,  her  face  resumed  its  natural  colour,  and  her  health  was 
perfectly  restored  in  a short  time.  Should  it  be  thought  necessary 
to  resort  to  an  emetic,  ipecacuanha  ought  to  be  preferred  above  all 
others,  because  of  its  less  violent  action  and  for  the  tonic  properties 
which  it  possesses. 

Electricity,  recommended  by  MM.  Sigaud  - Lafond,  Manduyt, 
Nauche,  Loudon,  and  others,  ought  not  to  be  employed,  we  think, 
except  with  great  circumspection,  and  after  we  have  restored  to 
the  blood  and  other  fluids  their  physiological  qualities.  Without 
this  precaution,  electricity  would  be  not  only  useless  but  dangerous, 
by  increasing  the  disorders  which  depend  upon  the  hyper hydrsemia, 
or  serous  plethora,  especially  in  those  accompanied  with  determina- 
tion of  blood  to  the  head  or  chest. 

Though  bleeding  was  prescribed  by  Van  Helmont,  Hoffman,  Sy- 
denham, Gardien,  Desormeaux,and  several  other  distinguished  prac- 
titioners, we  are  of  opinion  that  a small  revulsive  bleeding  may  be 
useful,  where  there  is  uterine  engorgement  with  haemorrhage,  and  in 
cases  where  the  patients  are  tormented  with  violent  palpitations 
and  symptoms  of  very  marked  serous  plethora.  We  conclude  by 
stating  that  the  nervous  symptoms,  the  gastralgia,  cephalalgia,  facial 
neuralgia,  melancholy,  etc.,  commonly  disappear  very  rapidly  under 
the  administration  of  iron  and  by  attention  to  hygieinic  indications,  and 
do  not  require  any  special  prescription.  Furthermore,  an  attempt  to 
recall  the  menses,  when  they  have  not  returned  spontaneously,  should 
never  be  made  until  after  the  chlorosis  is  cured,  and  we  are  convinced 


NYMPHOMANIA. 


513 


that  the  organs  of  assimilation  have  resumed  their  functions.  For 
this  purpose,  we  should  combine  emmenagogues,  such  as  saffron, 
aloes,  mugwort,  etc.,  with  the  filings  or  with  the  subcarbonate  of 
iron.  Rufus’s,  and  particularly  Fuller’s  pills,  in  doses  of  twenty 
grains  every  morning,  might  also  be  prescribed  conjointly  with  pedi- 
luvia,  hip-baths,  cups  to  the  thighs  and  about  the  pelvis;  and,  indeed, 
most  of  the  remedies  which  we  mentioned  when  speaking  of  the 
treatment  of  amenorrhoea. 

Should  we  discover,  as  Erasistratus  did  at  the  court  of  Seleucus, 
King  of  Syria,  an  amorous  inclination  to  be  the  cause  of  the  dis- 
ease, we  ought  always  to  consent  to  marriage,  not  immediately,  but 
where  a well-directed  treatment  has  restored  the  health,  which  would 
be  fully  established  by  following  the  precept  given  by  Hippocrates: 
" Equulem  virginibus  suadeo,  quibus  tale  quid  accidit,  at  citissime 
cum  viris  conjungantur ; si  enim  conceperint  ,sanse  evadwit.”  (Lib. 
de  morb.  virgin.) 

To  complete,  as  far  as  possible,  what  we  had  to  say  upon  the 
disease  which  forms  the  subject  of  this  chapter,  we  deem  it  proper 
to  subjoin  the  only  analyses  that  have  been  made  of  the  blood  of 
chlorotic  persons.*  By  taking,  as  the  point  of  comparison,  the  blood 
of  a healthy  female,  and  experimenting  on  one  thousand  parts,  the^e 
analyses,  due  to  MM.  Foedich  and  Lecanu,  have  furnished  the  fol- 
lowing results : 


Analysis  of  M.  Foedich : Cruor. 

Blood  of  a healthy  woman,  124.00 

Idem,  ....  144.00 

Blood  of  a chlorotic  patient,  91.41 

Idem,  ....  85.90 


Serum. 

Fihrine. 

Water. 

Iron. 

86.01 

25.11 

756.87 

S.01 

89.20 

25.01 

732.73 

9.01 

93.61 

6.40 

826.28 

3.30 

92.21 

6.31 

830.75 

5.01 

• Analysis  of  M.  Lecanu.— Blood  from  a chlorotic  patient:  water, 
862.40 ; globules,  55.15 ; albumen,  fixed,  fatty  and  extractive  matters, 
82.45;  total,  1.000.  We  see,  from  the  results  obtained  by  these  able 
experimenters,  that  no  doubt  remains  as  to  the  increase  of  the  water 
and  the  proportional  diminution  of  the  globules  and  iron  in  the  blood 
of  chlorotic  persons. 


OF  NYMPHOMANIA,  OR  FUROR  UTERINUS. 

By  nymphomania , or  furor  uterinus,\  is  now  understood  an 
exaggerated,  irresistible  and  insatiable  desire  urging  the  woman  to 
the  venereal  act.  This  affection,  upon  which  most  of  the  authors  of 
antiquity,  amongst  others  Hippocrates,  Galen,  Celsus,  Aretaeus,  Oriba- 
sius,  and  Paul  of  iEgina,  observe  entire  silence,  was  first  described  by 
Soranus,  under  the  title  of  ^tpoyavia,  ( Be  utero  et  mulieb.  pudendo;) 
and  from  this  author,  by  Aetius,  under  that  of  furor  ulerinus , and 
by  Moschion,  ( De  affect,  mulieb., cap.  28,)  under  the  denomination  of 
satyriasis.  The  physicians  who  have  written  upon  this  neurosis, 
disagree  as  to  its  seat:  some  have  placed  it  in  the  genital  organs,  while 
others  fix  it  in  the  encephalon.  The  former  opinion  is  maintained 

* [Vide  Andral’s  Pathol.  Haematol.,  Phil.,  1844,  pp.43,  52.— M.] 
f This  disease  is  also  designated  by  the  terms  metromania,  andromania,  erotomania, 
hysteromania,  clitorimania,  lypatia , etc. 

33 


514 


NYMPHOMANIA. 


by  Soranus,  Aetius,  Moschion,  Sennertus  and  Louyer-Villermay, 
and  the  latter  by  Willis,  Sydenham,  Boerhaave,  Georget,  Duges,  etc. 
Finally,  some  modern  authors,  amongst  others  MM.  Soby  and  Rech, 
professor  at  Montpellier,  in  whose  opinion  we  ourselves  agree,  regard 
nymphomania  as  resulting  from  a simultaneous  irritation  of  the  brain 
and  sexual  organs.  This  morbid  exaggeration  of  the  venereal  appetite, 
this  cestus  eroticus , is  less  a disease  than  a symptom  for  the  manifesta- 
tion of  which  is  required  the  concurrence  of  the  brain  and  the  organs  to 
which  erotic  sensations  are  referred.  The  point  of  departure  is  some- 
times in  the  brain,  and  sometimes  in  the  uterus  and  its  appendages. 
In  the  former  case,  the  disease  is  developed  under  the  influence  of 
moral  causes  which  secondarily  irritate  the  genital  parts,  and  in  the 
latter,  it  is  a primary  irritation  of  the  organs  of  generation  reacting 
sympathetically  upon  the  brain,  and  especially  on  the  cerebellum. 

The  affection,  which  may  appear  at  all  ages,  generally  attacks 
women  of  an  original  uterine  temperament,  which  is  determined  by 
the  predominance  of  the  sanguine  system,  and  extreme  irritability  of 
the  abdominal  viscera.  Women  of  this  constitution  have  some  of 
the  characteristics  of  Sappho  ; their  stature  is  small,  their  skin  dark, 
and  their  complexion  highly  coloured  ; in  them  the  breasts,  and  all 
the  attributes  of  puberty,  have  been  developed  at  an  early  period  ; 
the  clitoris  and  the  nymphm,  which  are  generally  of  anormal  length, 
are  endowed  with  exquisite  sensibility.  Young  widows,  who  have 
to  regret  frequent  engorgements,  public  girls  who  have  been  sud- 
denly deprived  by  forcible  seclusion  of  venereal  pleasures,  to  which 
they  had  abandoned  themselves  to  excess,  ardent  women,  married 
to  men  whose  cold  and  feeble  constitutions  prevent  often-repeated 
sexual  connection,  and  finally,  those  who  are  attacked  with  some 
chronic  cerebral  affection,  are  most  exposed  to  this  frightful  disorder, 
especially  when  they  inhabit  warm  climates,  in  which  the  passions 
are  most  vivid  and  the  imagination  most  exalted. 

There  are  some  women,  whose  genital  organs  acquire  such  a pre- 
ponderance, as  to  make  it  almost  impossible  for  them  to  control  the 
erotic  flame  that  devours  them ; such  was  the  young  girl  of  whom 
Buffon  speaks.  “ I have  seen,  and  I have  regarded  her  as  a singular 
phenomenon,  a girl  of  twelve  years  of  age,  a dark  brunette,  of  a bright 
and  highly-coloured  complexion,  of  small  stature,  but  already  fully 
formed,  with  a rounded  neck  and  embonpoint,  perform  the  most 
indecent  action  at  the  simple  appearance  of  a man ; nothing  could 
control  her  in  this,  neither  the  presence  of  her  mother,  nor  remon- 
strances, nor  punishments.  Yet  she  did  not  lose  her  reason,  and  the 
attack,  which  was  carried  to  such  a point  as  to  be  frightful,  ceased 
the  moment  that  she  remained  alone  with  women.”  ( Histoire  Na- 
turelle  de  Vhomme , de  la  puberte.)  Such,  also,  was  the  famous 
Messalina,  of  whom  Juvenal,  and  Pliny  the  naturalist,  give  us  the 
shameful  and  disgusting  history.  She  escapes,  during  the  night,  from 
the  bed  where  sleeps  the  Emperor  Claudius,  her  stupid  lord,  and 
disguised  in  the  dress  of  the  courtezan  Lycisca,  hastens  to  encounter 
the  brutality  of  the  vilest  debauchees  : 

“ Et  lassata  viris,  sed  non  satiata  recessit.” 


NYMPHOMANIA. 


515 


Amongst  the  causes  which  act  primarily  on  the  brain  and  second- 
arily on  the  sexual  organs,  should  be  included  all  conditions  capable 
of  producing  an  accession  of  excitement  in  the  centre  of  sensation, 
and  of  augmenting  the  exaltation  of  the  senses  and  ideas  ; such  as 
disappointed  love,  a concentrated  affection,  the  reading  of  lascivious 
and  impassioned  works,  the  sight  of  licentious  paintings,  erotic  and 
romantic  conversations,  intimate  communion  with  governantes  or 
corrupt  companions,  frequent  visits  to  balls  or  theatres,  the  too 
assiduous  cultivation  of  the  fine  arts,  accidental  sight  of  amorous 
interviews  and  the  influence  of  imitation  which,  in  this  case,  as  in 
most  of  the  nervous  affections,  is  followed  by  consequences  as  de- 
plorable as  they  are  frequent.  As  equally  capable  of  producing 
nymphomania  are  regarded  the  abuse  of  what  are  styled  aphrodisiac 
remedies,  or  of  spirituous  liquors,  the  immoderate  use  of  aromatics, 
and  perfumes  which,  by  exciting  the  brain  and  the  general  sensibility, 
arouse  and  exalt  the  venereal  appetite. 

The  causes  whose  action  is  felt  primarily  and  directly  upon  the 
uterus  and  its  appendages,  and  which  may  afterwards  react  sympa- 
thetically upon  the  brain,  are  solitary  pleasures,  the  abuse  of  coitus, 
an  herpetic  affection  or  prurigo  of  the  vulva,  irritation  of  the  clitoris 
and  nymphae,  inflammation  of  the  cervix  uteri,  and  of  the  ovaries; 
we  may  add,  that  the  age  of  puberty,  and  that  of  the  physiological 
cessation  of  the  menses,  as  well  as  the  epoch  of  their  flowing,  are 
circumstances  the  most  favourable  to  the  development  of  the  disease, 
which  now  occupies  our  attention.  There  is  another  frequent  and 
not  less  powerful  cause  of  exaggerated  erotic  exaltation,  which  is 
nothing  more  than  the  presence  of  ascarides,  which,  by  irritating  the 
rectum,  the  nymphae,  the  clitoris,  the  labia  majora  and  vagina,  induce 
in  the  genital  apparatus  an  excitement  and  pruritus,  which  compel 
the  patients  to  scratch  themselves  to  such  a degree  as  to  give  rise  to 
the  most  violent  erotic  desires.  Finally,  the  use  of  drastic  purga- 
tives, haemorrhoidal  fluxions,  and  especially  the  internal  or  external 
employment  of  cantharides,  have  sometimes  brought  on  an  exagge- 
ration of  genital  excitation. 

Symptoms. — In  the  beginning  of  the  disease,  the  female  expe- 
riences venereal  desires,  which  are  strongest  at  the  menstruating 
periods,  but  which  shame  compels  her  to  conceal.  The  care  which 
she  takes  to  hide  the  obscene  ideas  that  constantly  disturb  her  imagi- 
nation, as  well  as  the  illusions  of  platonic  love  which  has  irresistible 
charms  for  her,  exalts  her  imagination,  renders  her  sad,  taciturn  and 
melancholy ; she  loses  her  appetite  and  sleep,  and  seeks  solitude  in 
order  not  to  be  distracted  from  the  thoughts  with  which  her  imagina- 
tion is  constantly  preoccupied.  After  the  disorder  has  made  some 
progress,  far  from  seeking  to  hide  her  irresistible  passion,  the  patient 
employs  all  her  address  to  make  it  known  by  frequent  sighs,  by  encou- 
raging proposals,  by  voluptuous  attitudes,  and  finally  by  complete  for- 
getfulness of  all  modesty.  At  the  sight  of  one  of  the  masculine  sex  the 
pulse  of  the  nymphomaniac  is  agitated,  her  face  becomes  redder  and 
more  animated,  her  respiration  tumultuous,  her  senses  are  obscured, 


516 


NYMPHOMANIA. 


she  makes  indecent  proposals,  and  often  indecent  gestures ; finally, 
when  the  irritation  reaches  the  highest  point,  she  strikes,  and  tears 
every  thing  that  opposes  her,  and  at  last  falls  into  furious  delirium. 
In  addition  to  these  essential  and  characteristic  symptoms  of  the 
disease,  there  are  commonly  certain  symptoms  of  insanity  which 
may  be  remittent  or  perhaps  intermittent,  until  some  new  causes 
reproduce  them.  The  female,  who  is  always  affected  with  a general 
or  local  spasmodic  condition,  experiences  lassitude  of  the  extremi- 
ties, and  a sensation  of  pruriginous  heat  in  the  loins,  hypogastrium 
and  mammes ; the  urine,  variable  in  quantity,  is  always  clear,  and 
the  genital  parts,  which  are  red,  swollen,  and  constantly  irritated 
by  handling  or  illicit  manoeuvres,  are  commonly  the  seat  of  a sani- 
ous,  fetid,  and  sometimes  even  a purulent  discharge.  Lastly,  hur- 
ried respiration,  fatiguing  palpitations,  ardent  thirst,  grinding  of  the 
teeth,  spasm  of  the  oesophagus,  and,  in  some  cases,  hydrophobic 
symptoms  are  other  phenomena  attending  erotomania.  The  termi- 
nation of  the  disease  is  sometimes  fatal,  especially  when  coexisting 
with  organic  affections  of  the  ovaries,  uterus  and  its  appendages,  of 
which  examples  are  cited  by  Blancard,  by  Gesner,  and  by  Mor- 
gagni. In  some  cases,  the  attacks  of  furor  uterinus  follow  each  other 
with  great  regularity,  and  terminate  as  unhappily  as  pernicious  in- 
termittent fever.  Doctor  Jolly,  ( Diet . de  Mbd.  et  eh.  pr.,  t.  xii.  p.  96, 
1834,)  reports  a case  of  this  kind  from  Jauzion.  It  is  well  known 
that  Eusebia,  wife  of  the  Emperor  Constantine,  son  of  Constantine 
the  Great,  died  in  an  attack  of  furor  uterinus.  ( From  Zonaras,  hist, 
grascum.  annul.,  t.  iii.  p.  23.)  Nicolas  Blegny,  who  founded  the  Aca- 
demy of  recent  discoveries  in  Medicine,  in  1678,  relates  the  case  of  a 
woman  who,  after  several  paroxysms  of  furor  uterinus,  had  one  so 
violent,  as  to  cause  death  by  apparent  suffocation.  Paul  of  iEgina, 
likewise  cites  the  case  of  a beautiful  woman  of  Delphos,  who  pe- 
rished in  a paroxysm  of  the  same  kind.  Though  marriage  has 
sometimes  been  known  to  put  a stop  to  nymphomania,*  it  is  a means 
which  should  not  be  resorted  to  until  we  are  fully  assured  of  the 
etiology  of  the  disease,  and  of  the  proper  time  for  the  remedy. 
Suffice  it  to  say,  that  we  cannot  be  too  reserved  and  prudent,  when 
called  upon  to  give  advice  on  so  delicate  a point. 

The  treatment  of  nymphomania  must  depend  upon  the  causes 
and  primary  seat  of  the  disease,  that  is  to  say,  the  therapeutical 
means  are  to  be  applied  sometimes  to  the  brain,  and  at  other  times 
to  the  genital  organs,  in  which  is  seated  the  venereal  appetite  which 
overpowers  the  patient.  In  the  former  case,  which,  in  our  opinion, 
is  much  the  most  frequent,  we  ought,  especially  if  the  erotomania  be 
incipient,  to  repose  greater  confidence  in  hygieinic  measures  than  in 
drugs,  which  are  generally  inefficacious  in  opposing  a disease  whose 
source  lies  in  some  moral  cause.  We  must  begin,  therefore,  by  de- 
vising for  the  patient  some  means  of  distraction,  capable  of  diverting 

* Swenck  relates  that  an  Italian  woman,  who,  in  a paroxysm  of  erotic  insanity, 
had  escaped  from  her  house,  and  gone  to  a house  of  ill-fame,,  where  several  men  sati- 
ated their  passions  on  her,  recovered  her  health  in  the  midst  of  their  brutal  caresses. 


NYMPHOMANIA. 


517 


her  imagination  from  lascivious  thoughts,  for  which  purpose  we  may 
recommend  constant  occupation,  travelling,  and  exercise  by  walking. 

“ Otia  si  tollas  periere  Cupidinis  arcus.”  {Ovid.) 

Every  thing  capable  of  producing  erotic  excitement,  as  the  view 
of  statues  and  images,  the  reading  of  romances;  balls,  shows,  the 
society  of  men,  etc.;  should  be  avoided  with  the  greatest  care.  We 
should  always  seek  to  occupy  their  thoughts  with  objects  foreign  to 
their  passion,  and  to  contrive  that  they  may  associate  only  with  per- 
sons of  their  own  sex;  we  must,  at  the  same  time,  prescribe  the  use 
of  prolonged  warm  baths,  with  cold  affusions  to  the  head,  while 
the  patient  is  in  the  bath.  Emulsion  of  almonds,  with  addition  of 
nitrate  of  potash ; sedative  and  cold  drinks,  sweetened  with  syrup  of 
orgeat,  of  currants  or  marshmallows ; those  made  with  the  distilled 
waters  of  lettuce,  cucumber,  melon,  pumpkin,  or  water-lily,  and  ene- 
mata  of  the  same  nature,  with  addition  of  a few  grains  of  camphor ; 
finally,  whey ; broths  made  of  beets  and  sorrel,  and  of  chicken  or 
veal,  with  nitre ; lemonade,  a milk  and  vegetable  diet ; general 
bleeding  ; applications  of  leeches  behind  the  ears,  and  especially  to 
the  nucha,  are  all  useful  methods  of  treatment,  when  the  point  of 
departure  of  the  disease  is  seated  in  the  brain. 

If  the  nymphomania  depends  upon  some  local  cause  of  venereal 
excitement,  such  as  masturbation,  some  herpetic  affection,  prurigo, 
leucorrhoea,  the  presence  of  worms,  etc.,  we  must  try  to  allay  the 
pruriginous  sensation  which  stimulates  the  patient  to  the  revolting- 
excesses  so  hurtful  to  her,  by  combining  with  the  various  means 
already  indicated  various  tonics;  for  example, emollient  and  narcotic 
injections,  and  applications  to  the  genital  parts  of  cloths  wet  with 
decoction  of  poppy-heads,  of  lettuce,  of  henbane,  of  cicuta,  etc.  We 
might,  also,  with  the  same  view,  resort,  to  inunctions  of  cucumber 
ointment  with  opium,  or  of  a liniment  made  of  lime-water  and  olive 
oil.  Small  enemata  of  milk  with  addition  of  a few  grains  of  cam- 
phor, and  the  internal  employment  of  camphor,  strongly  recom- 
mended by  Ettmuler  ( De  mnrb.  mnlier .,  cap.  2),  in  a dose  of  five  to 
fifteen  grains  in  a 'mixture,  are  means  whose  efficacy  has  been  recog- 
nized from  the  highest  antiquity,  and  is  consecrated  by  the  old  adage  : 

“ Camphora  per  nares  castrat  odore  mares.” 

To  diminish  the  venereal  orgasm,  some  authors  have  proposed 
cicuta,  but  the  anti-aphrodisiac  virtue  of  this  plant  is  far  from  being 
proved,  although  Saint  Basil  has  said,  ( Homil . v.  supra  hexaemer :) 
“ Se  vidisse  quasdam  foe  minus,  qux  potione  cicutse  extinxerint  rabio- 
sas  cupiditates Finally,  for  the  purpose  of  quelling  the  erotic  de- 
sires, Doctor  Coster  has  proposed  the  employment  of  tartar  emetic 
in  small  quantities,  one  or  two  grains  in  a pint  of  water,  to  be  taken 
in  teacupful  doses  every  hour,  so  as  to  excite  nausea  without  occa- 
sioning vomiting.  According  to  this  physician,  the  nausea  and  mus- 
cular prostration  which  result  from  the  use  of  this  potion,  scarcely 
ever  fail  to  produce  the  desired  effect.  It  is  well  to  remark,  also, 
that  every  thing  capable  of  exciting  the  genital  organs  must  be  re- 
moved from  the  bed  upon  which  the  patient  lies.  For  example,  very 


518 


NYMPHOMANIA HYSTERIA. 


soft  mattresses,  feather  beds,  and  beds  made  of  down  must  be  for- 
bidden, and  one  made  of  straw  is  to  be  preferred  instead,  or  else  it 
should  consist  of  a simple  hair  mattress.  We  should  reject,  also,  as 
dangerous  and  immoral,  the  titillation  of  the  clitoris,  advised  by  some 
authors,  particularly  by  Varande,  (De  morb.  rrnilier .,  lib.  i.  cap.  5.) 
Excision  of  the  clitoris,  likewise,  would  be  useless  in  gpposing  true 
erotomania,  in  the  treatment  of  which  Levret  and  some  other  authors 
have  vainly  employed  it.  This  operation,  performed  several  times 
by  MM.  Dubois  the  elder,  by  Richerand  (Nosog.  chir .,  t.  iv.),  and 
by  Grsefe  ( Nouv . bibl.  Med.,  t.  ix.,  p.  256,  1825),  etc.,  has  served 
merely  to  arrest  the  vicious  habits,  which  might  often  be  remedied 
by  means  of  the  tincture  of  M.  Gerentel,  or  the  ingenious  apparatus 
of  Professor  J.  Cloquet,  which  consists  of  a sort  of  wire-work  whose 
meshes  are  so  close  as  to  prevent  the  passage  of  the  finger.  To  the 
employment  of  the  various  means  we  have  mentioned,  should  still 
be  added  a Pythagorean  regimen,  a milk  and  vegetable  diet,  absti- 
nence from  stimulating  drinks  and  food,  while  in  the  intervals  of  calm 
we  must  remind  the  patient  of  her  duty  to  herself  and  family,  which  is 
dishonoured  by  her  shameless  practices.  Finally,  where  the  nympho- 
mania has  reached  the  highest  degree  of  violence,  the  disease,  which 
in  that  form  is  generally  incurable,  would  simply  require  the  treatment 
proper  for  mania.  We  refer  our  readers  to  Pinel’s  treatise  upon  mental 
alienation,  1809,  and  to  the  work  just  published  by  M.  Esquirol, 
entitled  Des  Maladies  Meat.,  etc.  t.  ii.  p.  32,  1838.  We  cannot  too 
strongly  recommend,  likewise,  the  excellent  work  of  M.  F.  Voisin, 
whose  title  is : Des  causes  Morales  phys.  des  Maladies  Meat,  et  de 
quelques  autres  affect,  new.,  idles  que  Vhyst'erie , la  nymphoma - 
nie,  etc.,  1836. 

OF  HYSTERIA  AND  OTHER  SPASMODIC  DISEASES  OF  WOMEN. 

From  the  earliest  periods  to  the  present  time, most  authors  who  have 
written  on  the  disease  designated  by  the  term  hysteria ,*  have  involved 
themselves  in  vain  arguments,  in  specious  explanations  and  rash 
theories  upon  its  nature,  seat  and  causes.  Without  wishing  to  recall 
all  that  has  been  said  upon  the  subject,  we  shall  proceed  to  state  in 
a few  words  the  opinions  that  have  been  put  forth  by  different 
writers.  We  ought,  however,  to  inform  our  readers  that,  in  order  to 
avoid  digressions  and  repetitions,  and  especially  with  a view  to  a 
more  methodical  arrangement,  we  have  preferred  to  proceed  by  ana- 
logy rather  than  to  follow  the  chronological  order,  that  is  to  say,  to 
group  together  the  opinions  bearing  the  strongest  resemblance  and 
relations  to  each  other. 

The  various  opinions  which  have  prevailed  as  to  the  seat  of  hys- 
teria, may  be  reduced  to  four:  1.  Some  have  placed  the  seat  of  the 
disease  in  the  uterus,  whether  it  were  the  effect  of  change  of  position, 

* This  disease  has  been  called  by  various  denominations,  amongst  others,  vs-rcpi^v 
hysterica,  hystencia,  hysterical  spasm;  suffocation  of  the  womb,  hysterical  vapours, 
maux  de  nerfs,  attaques  de  nerfs,  metronervie,  mal  de  la  mere,  hystericism,  encepha- 
lie  spasmodique,  etc.,  etc.  * 


HYSTERIA. 


519 


or  of  alterations  of  the  organ,  as  believed  by  Hippocrates,  Plato, 
Aretaeus,  Caelius-Aurelianus,  Soranus,  Primrose,  Haller  and  Duret; 
whether  it  depended  upon  a retention  or  alteration  of  the  sperm  or 
of  blood  retained  in  the  viscus,  and  whence  arise  malignant  vapours, 
afterwards  dispersed  through  the  whole  body,  as  supposed  by  Galen, 
Ahrun,Fernel,  Pitcairn,  Charleton,Zacutus-Lusitanus,  Forestus,  Guil- 
laume de  Baillou,  Thomas  Burnet,  Mercalus,  Sennertus,  N.  Chesneau 
and  Laz  Riviere ; or,  lastly,  whether  the  disease  were  the  consequende 
of  some  modification  of  the  uterine  nervous  system,  acting  sympathe- 
tically on  the  general  nervous  system,  as  set  forth  by  Aetius,  Astruc, 
Cullen,  Pinel,  Lieutaud,  Vigarous,  Beaumes,  Louyer-Villermay,  Ra- 
pon,  Duges,  Foville,  Dubois,  of  Amiens,  and  by  most  modern  authors. 
Pujol,  of  Castres,  and  M.  Lisfranc,  who  are  of  this  opinion,  admit, 
nevertheless,  that  chronic  inflammation  of  the  uterus  or  ovaries* 
may  often  be  the  primary  cause  of  hysteria. 

2.  Other  writers  have  supposed  the  disease  to  be  seated  in  the 
general  nervous  system  ; of  these  some  see  nothing  in  the  disease  but 
irritation  or  irregular  movements  of  the  nerves ; others  think  that  the 
disease  should  be  attributed  to  an  alteration  of  the  nervous  fluid,  or 
to  some  vitiation  of  the  animal  spirits.  We  must  refer  to  this  class 
the  opinions  of  Dutnoulin,  de  Loob,  Boerhaade,  Alberty,  Neuter, 
Gorter,  Sauker,  Raulin,  Pomme,  Lory,  Tissot,  Ridley,  F.  Hoffmann, 
Blackmor,  Pressavin,  Whytt,  Viridet,  Sauvage,  Perry,  Linnaeus,  Gar- 
dien,  etc.  We  may  attach  to  the  same  class,  also,  the  atony  of  the 
spirits  (ata^a  spirituum  anirnaliam)  of  Sydenham,  the  lesion,  what- 
soever it  be,  of  the  ganglionic  system  of  Bichat,  and  the  prostration  of 
the  whole  system  of  strength  of  the  vital  principle,  to  which  Barthez 
assigns  so  important  a part. 

3.  Among  the  physicians  who  have  referred  the  point  of  departure 
of  hysteria  to  the  brain,  are  included  Ch.  Lepois,  Willis  and  Geor- 
get:  Barbeyrac  thought  it  was  the  effect  of  an  acid  and  bilious  prin- 
ciple conveyed  to  the  brain  ; Schacht  supposed  it  .to  depend  upon  a 
disturbed  course  of  the  spirits,  whose  source  is  in  the  semorium  com - 
mttne  and  in  the  nerves:  again,  M.  Amard  has  referred  the  origin  of 
hysteria  to  the  inferior  portion  of  the  medulla  spinalis.  M.  Brachet, 
of  Lyons,  [Recherches  sur  1' hysteric,  etc.  p.  143,  1832,)  thinks  that 
the  disease  has  its  seat  in  the  central  nervous  system,  and  that  it  con- 
sists of  a peculiar  mode  of  excitation  and  perversion  of  this  system, 
Gardien  has  imagined  that  the  starting-point  of  the  evil  might  very 
well  be  in  the  pulmonary  and  cardiac  plexuses. 

* Vesalius  (de  hum.  corp.  fabr.  lib.  v.  cap.  15),  speaks  of  having  found  the  ovaries 
of  hysterical  women  larger  than  a trap-ball,  and  filled  with  a yellow  fluid.  Riolan 
(Anthropol.,  lib.  ii.  p.  55),  asserts  that  he  saw  an  ovary  larger  than  the  fist,  in  a female 
affected  with  the  same  disease.  Diemerbroeck  (Anat.lib.de  ventre  inferiore,  cap.  24), 
also  states  that  he  found  around  the  uterus  of  a person  who  died  in  a hysterical  parox- 
ysm, a tumour  filled  with  a yellow  liquid;  finally,  S.  N.  Binninger  (Observ.  et  curat. 
Med.  Aut.  ii.,  obs.  90).  likewise  speaks  of  having  seen  the  ovaries  and  Fallopian 
tubes  of  a woman  who  died  with  the  same  disease,  enlarged  and  infarcted  with  a white 
thickened  tumour.  Riverius  (loc.cit.  cent.  i.  obs.  60),  found  an  ovary  of  a dark  colour, 
and  of  the  size  of  a small  egg;  again,  Morgagni  (epist.  65,  No.  21)  met  with  two  ova- 
ries in  a scirrhous  condition,  and  M.  Rullier  (dissert  inaug.)  discovered  that  they 
were  tumefied  in  a girl  who  had  perished  in  an  attack  of  hysteria. 


520 


HYSTERIA. 


4.  Some  authors  have  fixed  the  origin  of  the  affection  which 
engages  our  attention  in  the  stomach  and  its  neighbourhood,  (Parcel, 
Hunault,  Pitcairn,  Vogel);  in  the  bowels  and  stomach,  (Jean-Maria, 
Hamilton);  in  the  lungs  and  heart,  (Hyghmore);  in  the  abdominal 
nervous  system,  and,  especially,  the-  vena  portas,  (Stahl). 

As  most  of  these  opinions  rest  upon  mere  hypotheses,  errors  and 
isolated  facts,  or  such  as  have  been  observed  with  preconceived 
ideas,  as,  moreover,  the  physiological  inductions  which  gave  rise  to 
them,  were  not  illuminated  by  the  lamp  of  pathological  anatomy, 
we  deem  it  proper  to  abstain  from  discussing  their  value,  and  to  con- 
tent ourselves  with  saying  that  if  a more  accurate  knowledge  of  the 
seat  of  the  disease  is  ever  to  be  attained,  it  can  only  be  by  more  care- 
ful analysis  of  the  symptoms,  and  by  seeking  to  discover  which  of 
the  organs  receive  the  principal  influence  of  the  various  pathogenic 
causes.  Nevertheless,  we  must  add  that  most  physicians  of  the 
present  day  regard  the  uterus  as  the  starting-point  of  the  different 
phenomena  whose  sum  constitutes  hysteria.  Some  practitioners,  and 
amongst  them,  M.  Boisseau,  suppose  the  disease  to  be  the  effect  of  a 
simultaneous  irritation  of  the  uterus  and  encephalon.  If  it  is  allow- 
able for  us  to  put  forth  an  opinion  as  to  the  probable  sources  of  the 
disease,  founded  upon  the  cases  which  have  fallen  under  our  own 
observation,  and  which  we  have  compared  together,  and  with  a great 
number  of  others  reported  by  different  authors,  we  should  say  that 
hysteria,  properly  so  called,  has  its  principal  seat  in  the  nervous  sys- 
tem of  the  uterine  apparatus,  and  that  it  consists  of  a special  and 
sui  generis  mode  of  excitation  and  perversion  of  this  system  reacting 
sympathetically  upon  the  general  nervous  system ; we  state  farther, 
that  this  peculiar  excitation,  this  morbid  modification  of  the  uterine 
innervation,  may  itself  have  for  its  origin,  either  a local  irritation, 
often  inappreciable,  or  a sympathetic  one,  resulting  from  a moral 
cause,  or  from  the  pathological  condition  of  some  organ  or  different 
apparatus  with  which  the  uterus  has  bonds  of  union  more  or  less 
direct. 

As  the  characters  of  hysteria  are  too  numerous  and  variable  to 
allow  of  our  giving  a short  and  precise  description  of  it,  we  shall 
rest  content  with  saying,  that  it  consists  of  a lesion  of  the  uterine 
apparatus,  giving  rise  to  paroxysms  devoid  of  fever,  which  are  ma- 
nifested less  by  local  symptoms  than  by  a sense  of  suffocation  and 
strangulation,  followed  by  more  or  less  complete  loss  of  conscious- 
ness, and  accompanied  by  convulsive  and  spasmodic  phenomena  in 
the  orgahs  of  organic  life,  and  the  life  of  relation. 

[It  might,  perhaps,  have  been  deemed  better  to  rest  content  with  the  ex- 
position above  given  of  the  author’s  views,  as  to  the  essential  seats  of  the 
hysteric  malady  ; the  more  particularly,  as  notwithstanding  the  respectable 
opposition  of  many  distinguished  writers,  I agree  with  him,  that  it  is  to  be 
sought  for  in  lesions  of  the  nervous  apparatus  of  the  uterine  system.  Yet,  I beg 
leave  to  say,  that  notwithstanding  the  existing  and  past  dissidence  of  profes- 
sional opinions  on  this  point,  it  would,  one  should  think,  suffice  for  the  con- 


HYSTERIA. 


521 


vincement  of  an  unprejudiced  mind,  to  examine  even  cursorily  Dr.  Tiede- 
mann’s  plates,  in  his  Tabulae  nervorum  uteri  humani;  and  the  recently  pub- 
lished engravings  of  the  same  series  of  nerves,  in  Dr.  Robert  Lee’s  work  on 
Midwifery.  The  vast  complicity  of  the  reproductive  nerves  with  the  entire  of 
the  ganglionic  system  and  the  cerebro-spinal  nerves  therein  displayed,  would 
seem  sufficient  to  remove  all  doubt  as  to  the  disturbing  power,  which,  when 
modified  by  disease,  that  system  could  exert  on  the  other  members  of  the 
ganglionic  innervation,  as  well  as  on  the  brain-nerves,  and  those  of  the  spinal 
cord.  It  is  scarcely  to  be  deemed  philosophical  to  look  upon  the  working 
of  the  organisms,  as  a mere  concurrence  of  a given  catalogue  of  organs  in 
carrying  on  the  business  of  general  life,  by  contributing  each  its  part  in  the 
grand  scheme  of  the  hasmatosis,  the  calorification,  the  innervation,  the  assi- 
milation, and  secretion  merely,  and  without  reference  to  the  constitutional 
influence  that  each  member  of  the  confederacy  exerts  on  its  co-members.  It 
is  like  looking  at  the  results  of  the  operations  of  a great  commercial  part- 
nership, in  which  each  partner  does  his  part  in  the  correspondence,  the 
buying  and  selling  merely,  when,  in  fact,  each  such  partner  exerts  a power 
to  modify  the  activity  of  every  other  member  of  the  concern,  beyond  and 
besides  his  special  routine  of  daily  toil.  Now,  in  a community  of  vital  organ- 
isms, the  nature,  whether  physical  or  physiological  of  the  substance  called 
liver , is  so  special,  so  peculiar,  that  throughout  the  whole  range  of  the  tissues, 
there  is  no  other  substance  at  all  like  it — it  has  a peculiar  power,  a peculiar 
metabolic  or  changing  power,  which  it  exercises  for  the  conservation  of 
various  other  parts  of  the  economy.  The  same  holds  good  as  to  brain , 
spleen,  the  stomach,  the  kidneys,  &c.  Each  one  enjoys  not  an  inde- 
pendent, but  a special  life,  and  therein  possesses  the  power  to  modify  and 
control,  to  a certain  extent,  all  other  special  lives  ; and  this,  too,  without  rela- 
tion to  the  mere  secerning  and  circulating  power  it  enjoys,  but  in  a more 
extended  degree,  by  virtue  of  that  special  and  peculiar  life,  since  doubtless 
the  life  even  of  every  cytoblast  is  peculiar  and  special,  and  then  a fortiori  is 
it  so  as  to  the  organic  products  of  the  cytoblasts  that  compose  all  our  phy- 
sical frame. 

But  it  cannot  be  disputed,  that  the  organs  exercise  each  a special  influ- 
ence on  the  blood,  that  pabulum  of  the  life  and  common  bond  of  the  mem- 
bers of  it.  The  entire  vascular  system  is  lined  with  a membrane,  called  by 
Bichat,  the  common  membrane  of  the  sanguiferous  system.  But  that  mem- 
brane is  by  no  means  a unit.  As  the  mucous  membrane  is  not  a unit,  but 
is  different,  as  it  serves  in  different  places  to  line  organs  wholly  unlike  in 
their  nature  and  offices,  so  the  common  membrane  of  the  blood-vessels  is 
everywhere  different,  as  in  the  vessels  of  the  brain,  the  liver,  the  stomach, 
the  reproductive  organs,  &c. 

Let  that  membrane  be  regarded  as  constituting  one  single  cavity  or  cyst, 
the  angeiotenic  cyst,  containing,  as  in  a simple  single  sac,  all  the  blood  of  the 
subject,  computed  to  amount  to  six  hundred  ounces.  Let  it,  fur  the  argu- 


522 


HYSTERIA. 


ment  sake,  be  conceded,  that  the  blood  in  this  cyst,  as  is  the  fact,  is  perpe- 
tually changing  its  place  of  contact  with  the  surface,  so  that  the  discs  come 
to  be  placed  in  succession,  in  contact  with  the  interior  surface  of  every 
organ  of  the  body  ; brain,  lungs,  stomach,  womb,  &c.  Can  we  reasonably 
then  doubt,  that  each  one  of  these  organs,  so  different  in  nature  and  power, 
taking  out  from,  and  depositing  in  the  sanguine  mass  the  materials  for  its 
accretion,  and  the  detritus  of  its  substance,  can  we  doubt,  I say,  of  the 
powerful  influence  each  one  of  them  can  exert  on  the  constitution  of  the 
blood  ? Is  it  not  true,  that  each  organ  can  and  does  then  modify  the  crasis 
of  the  blood,  influence  the  hsematosis,  and  thereby  rule  and  domineer  when 
diseased,  over  the  law  of  the  life  of  the  organisms,  by  this  single  power. 

Yet  this  is  not  the  sole  power  they  can  exert,  and  it  is  specified  merely  as 
one  single  one,  and  to  show  that  it  is  not  impossible  to  trace  the  steps  by 
which  diseased  actions  spread  themselves  abroad  through  the  constitution. 

There  are  other  powers  to  disturb  and  to  preserve  beyond  this  one,  and 
even  exceeding  it.  Such  are  the  nervous  relations  and  connections,  which, 
like  the  radii  and  circles  of  the  spider’s  web,  awaken,  when  touched,  the 
sensibility  of  every  limitrophic  organ,  of  every  fibre  to  which  they  are  distri- 
buted. Of  these  nervous  influences,  I have  here  no  time  to  speak,  nor  is 
it  necessary  for  my  purpose  to  do  so;  but  I beg  leave  to  ask  the  attention 
of  the  reader,  to  the  remarkable  case  related  at  page  83,  as  exhibiting  an 
instance  of  peculiar  power  in  a system  of  tissues,  even  over  the  morbid 
products  of  those  textures  themselves.  In  that  case  it  is  shown,  that  the 
tissue  of  which  the  clitoris  is  composed,  could  preserve  free  from  putridity, 
and  almost  from  decomposition,  a quantity  of  blood,  amounting,  at  least,  to 
more  than  twenty  ounces,  for  fourteen  or  fifteen  years,  precisely  in  the  same 
manner  as  blood  is  often  preserved  for  months  and  years,  in  the  cavity  of 
the  obturated  womb  and  vagina,  in  cases  of  imperforate  hymen,  and  other 
atretism  of  the  passages,  as  in  the  case  I have  related,  also,  at  p.  102,  of 
this  work. 

Is  there  any  other  tissue,  save  the  reproductive  tissue,  that  possesses  this 
power  ? Certainly  aneurismal  sacs  do  not  possess  it,  and,  so  far  as  I know, 
none  others. 

But  there  is  another  consideration  that  I desire  to  lay  before  the  reader; 
on  which  account  I add,  that  the  great  reproductive  force  of  all  living  beings, 
going  from  the  top  of  the  scale  down  to  the  lowest  infusory  monas  or  vorti- 
cella,  is  dependent  on  a reproductive  tissue  or  substance,  implanted  some- 
where within  the  constitution  of  the  individual.  That  great  force  is  one  of 
the  first  necessity  in  the  world,  and,  existing  as  it  does,  it  could  only  be  set 
in  motion  by  an  aphrodisiac  or  erotic  sense  and  appetency.  This  it  is, 
that  in  all  the  tribes  of  beings,  constantly  provokes  them  to  fulfil  the  great 
ordinance  to  go  forth,  increase  and  multiply,  and  fill  the  whole  earth.  This  is 
binding,  not  only  on  the  mammals,  but  even  on  the  hermaphrodite  annelides 
and  molluscs.  This  law  is  so  general,  so  indispensable,  that  without  its  provi- 


HYSTERIA. 


52  3 


sions,  the  genera  and  the  species  would,  without  exception,  in  a few  years 
be  annihilated,  leaving  the  globe  a vast  desolation,  and  without  a living  wit- 
ness to  the  glory  and  power  of  its  Divine  author. 

It  is  true,  then,  that  this  great  force  exists,  but  it  exists  in  the  reproduc- 
tive substance,  in  the  ovaries  and  womb,  and  there  alone  in  the  female ; yet, 
so  influential  and  diffusive  is  it,  that  through  the  nerves,  it  irradiates  every 
part  of  the  economy  ; the  senses,  and  the  innermost  recesses  of  the  organisms 
feel  and  obey  its  provocations  on  the  eye,  the  lip,  the  tactile  surface,  and 
even  in  the  simple  consciousness  of  presence  and  power,  or  in  the  imagina- 
tion itself.  The  faintest  perception  of  the  erotic  odour  is  sufficient  to  wake 
it  from  the  sleep  of  days  or  weeks,  and  an  internal  and  pervading  sense, 
which  is  irradiated  by  the  reproductive  tissues,  fills  and  influences  the  whole 
community  of  the  organisms.  Is  it  not  then  a pervading  vital  force  ? Is  it 
not  a constitutional  sense ? Is  there  any  other  one  amongst  the  whole  system 
of  organs  that  enjoys  a power  equally  urgent,  when  it  becomes  excited  by 
disease;  or  when  disordered  by  whatsoever  cause,  it  becomes  capable  of 
carrying  confusion  into  every  department  where  it  may  rave  and  rage  in  its 
caprice  or  fury?  Is  there  any  serious  difficulty,  then,  or  want  of  ratiocination 
in  arriving  at  the  conclusion,  so  much  disputed,  that  disordered  and  modified 
states  of  the  reproductive  structures  may,  and  indeed  do,  excite  all  the  won- 
derful and  mysterious  phenomena,  whether  physical,  physiological,  or  psy- 
chological of  the  hysteric  malady. — M.] 

The  causes  of  hysteria  may  be  divided  into  predisposing  and  de- 
termining. Though  the  former  class  is  exposed  to  some  objections, 
it  is  generally  admitted,  that  hereditary  transmission  mentioned  by 
Willis  and  Pomme,  a feeble  constitution,  residence  in  large  cities, 
idleness,  an  effeminate  moral  and  physical  education,  exquisite 
nervous  sensibility,  ardent  temperament,  and  erotic  idiosyncrasy, 
are  causes  which  favour  the  development  of  the  disease.  It  is  pro- 
per, also,  to  remark,  that  the  affection  is  most  common  between  the 
epoch  of  puberty  and  the  cessation  of  the  menses;  nevertheless,  it  has 
sometimes  been  observed  in  young  girls  before  menstruation,  and  in 
women  who  have  passed  the  critical  age.  Chambon  relates,  in  his 
Treatise  upon  the  diseases  of  women,  that  one  of  his  relations  be- 
came hysterical  at  the  age  of  eighty-three  years.  We  add,  that 
it  more  particularly  attacks  girls  who  are  on  the  point  of  being 
regulated,  young  widows,  women  who  have  had  no  children,  those 
who  are  approaching  the  critical  period,  and  finally,  those  who  are  fat, 
plethoric,  and  sanguine,  and  in  whom  the  menstrual  function  is  com- 
monly painful  and  irregular. 

The  determining  causes  of  hysteria  are  : the  menstrual  effort  at 
the  epoch  of  puberty ; suppression  of  the  menses,*  or  their  difficult 

* Suppression  of  the  menstruse  is  often  a precursory  or  coincident  phenomenon, 
and  not  the  cause  of  hysteria;  this  is  proved  by  the  fact,  that  the  disease  has  been 
known  to  persist  without  the  slightest  amendment,  in  a great  number  of  eases,  even 
after  the  periodical  discharge  has  been  successfully  restored.  We  also  remark, 
that  suppression  of  the  lochia,  which  has  been  regarded  as  an  occasional  cause  of 


524 


HYSTERIA. 


discharge ; uterine  plethora ; forced  continence  ; abuse  of  coitus ; 
masturbation,  and  all  circumstances  capable  of  producing,  main- 
taining, or  increasing  irritation  of  the  uterus,  and  especially  of  the 
ovaries.  The  disease  may,  also,  have  as  determining  causes,  the  in- 
stinct of  imitation,*  the  vivid  emotions  of  the  soul,  such  as  transports 
of  anger,  fright,  violent  and  sudden  disappointment,  the  uneasiness 
produced  by  love,  the  reading  of  highly  wrought  works,  erotic  con- 
versation, the  sight  of  some  ghastly  and  bloody  spectacle,  or  of  a 
licentious  scene ; the  impression  produced  by  a tragical  representa- 
tion, by  sombre,  mysterious,  pathetic,  or  too  animated  music ; finally, 
all  the  circumstances  that  produce  violent  movements  in  the  eco- 
nomy, or  suddenly  recall  painful  and  lasting  impressions. 

Whatever  be  the  causes  of  hysteria,  women  affected  with,  or  pre- 
disposed to  the  disease,  generally  exhibit  all  the  signs  of  a very 
excitable  temperament ; their  characters  are  commonly  marked  with 
a shade  of  levity,  frivolity,  or  remarkable  obstinacy  ; they  are  com- 
monly capricious  and  irascible;  their  temper  is  uncertain  and  wa- 
vering, and  the  most  trivial  circumstances  make  them  pass  from 
immoderate  joy,  from  the  most  noisy  laughter,  the  most  affection- 
ate caresses,  to  melancholy  mingled  with  sighs,  tears,  sobs,  and  the 
bitterest  reproaches ; finally,  they  experience,  in  the  highest  degree, 
that  state  of  anxiety,  of  indefinable  melancholy  and  suffering,  of 
which  eminently  nervous  persons  complain. 

The  symptoms  of  hysteria  are  as  variable  as  the  causes  which 
produce  them.  An  entire  volume  would  not  suffice,  were  it  neces- 
sary for  us  to  describe  and  trace  all  their  varieties  as  mentioned  by 
authors,  for  we  should  be  in  some  sort  compelled  to  describe  nearly 
every  form  of  disease,  and  thus  justify  what  was  said  by  F.  Hoff- 
mann, when  treating  of  hysteria  : non  est  morbus  unus , sed  potius 
morborum  cohors.  Is  it  not  known,  moreover,  that  the  number  and 
variety  of  the  symptoms,  and  various  forms  of  the  disorder,  led  to  their 
being  compared  by  Sydenham,  to  the  metamorphoses  of  Proteus, 
and  to  the  changing  colours  of  the  chameleon.  We  shall,  therefore, 
confine  ourselves  to  a description  of  the  phenomena  which  the  disease 
most  frequently  presents  at  its  commencement,  and  during  its  pro- 
gress. 

Though  the  hysterical  paroxysm  sometimes  attacks  suddenly,  and 
without  precursory  signs,  it  is  generally  preceded  for  several  minutes, 
an  hour  or  two,  or  even  for  days,  by  some  derangement  of  the  eco- 
nomy, by  feelings  of  malaise,  depression  and  uneasiness ; to  these 
prodromic  phenomena,  are  added  frequent  yawning,  pandiculation, 

hysteria,  is  itself  nothing  more  than  a symptom  of  a puerperal  affection,  complicated 
with  nervous  symptoms. 

* M.  Andral  relates  in  his  course,  the  case  of  a young  girl,  who,  at  a boarding- 
school,  fell  into  a paroxysm  of  hysteria  in  the  presence  of  her  companions;  soon 
after,  so  large  a number  were  attacked  with  the  same  disease,  as  to  make  it  necessary 
to  close  the  school  for  a considerable  period.  Thouret  and  Bailly  cite  an  analogous 
case,  which  happened  upon  the  occasion  of  a first  communion  at  St.Ruch.  A young 
girl  was  attacked  with  an  hysterical  paroxysm,  and  the  same  accident  soon  happened 
to  several  young  persons  who  were  witnesses  of  it.  It  is  probable  that  these  attacks 
were  the  result  of  a cerebral  spasm,  of  which  we  shall  soon  speak,  and  not  of  true 
hysteria,  which  scarcely  ever  appears  before  the  age  of  puberty. 


HYSTERIA. 


525 


flashes  of  heat,  redness  of  the  face,  paleness  and  coldness  of  the  ex- 
tremities, palpitations,  numbness  and  cramps  of  the  limbs,  intense 
cephalalgia,  a state  of  moroseness,  and  sadness  accompanied  by  tears, 
and  sighs  which  alternate  in  certain  cases,  with  immoderate  and 
causeless  laughter.  * 

At  the  commencement  of  the  paroxysm,  the  patients  feel  a sensa- 
tion of  obscure  tension  and  spasmodic  constriction,  analogous  to  that 
produced  by  the  movement  of  some  globular  body,  which,  after 
having  performed  various  circumvolutions  in  the  cavity  of  the  abdo- 
men, ascends  chiefly  on  the  left  side,  towards  the  stomach  and  thorax, 
and  following  the  course  of  the  oesophagus,  produces  a sense  of 
tightening  in  the  throat,  which,  in  very  severe  cases,  occasions  dread 
of  suffocation. 

This  sort  of  mysterious  ball,  which  mounts,  by  an  oscillating 
movement,  from  the  hypogastrium  to  the  throat,  gives  rise  to  a feeling 
of  weight  in  passing  through  the  epigastric  region,  and  to  painful 
constriction  and  fatiguing  palpitations  at  the  praecordia.  When  the 
paroxysm  is  a mild  one,  slight  convulsions,  and  not  unfrequently 
impaired  hearing,  and  a momentary  feebleness  of  the  intellectual 
faculties,  are  observed.  When,  on  the  other  hand,  it  is  more  violent, 
partial,  or  even  complete  attacks  of  syncope  occur,  which  last  but  a 
few  moments,  after  which  the  paroxysm  sometimes  ceases.  In  some 
cases,  convulsive  movements  of  the  muscles  of  the  limbs  and  trunk 
appear,  which  are  generally  so  violent  as  to  make  it  difficult  for 
several  persons  to  hold  the  most  delicate  woman,  who,  in  spite  of  the 
efforts  of  the  assistants,  struggles,  rolls  and  twists  herself  upon  her 
bed*  When  not  pevented,  they  meet  with  terrible  falls,  strike 
themselves  upon  the  breast,  tear  out  their  hair,  and  forcibly  thrust 
aside  any  object  they  encounter.  The  body,  which  is  stiffened, 
bends  forwards,  backwards,  to  the  right  and  left,  just  as  in  epilepsy. 
The  jaws  are  shut,  and  the  eyelids,  which  almost  always  cover  the 
whole  globe  of  the  eye,  during  the  attack,  are  contracted  and  agitated 
with  rapid  and  continual  tremors.  The  nostrils  are  wide  open,  but 
the  cheeks  and  other  portions  of  the  face  commonly  experience  no 
other  movements  than  those  in  co-ordination  with  the  cries  and 
forced  respiration  of  the  patients. 

While  the  attack  lasts,  the  head  is  almost  always  carried  back- 
wards; the  anterior  part  of  the  neck  is  the  seat  of  a tension,  which 
causes  the  woman  to  apply  the  hand  frequently  against  the  region  of 
the  larynx,  which  she  presses  and  scratches  as  though  she  wished  to 
remove  some  obstacle.  If  the  patient  is  thin  and  of  feeble  constitution, 
the  cheeks,  the  lips  and  the  alse  nasi  are  pale  and  cold:  in  some  cases, 
especially  where  the  female  is  fat  and  plethoric,  the  face  is  florid, 
warm  and  red,  particularly  on  the  cheek  bones.  The  abdomen  and 
thorax  are  distended  or  contracted  in  a permanent  or  alternate  man- 
ner, and  the  edge  of  the  false  ribs  is  commonly  the  seat  of  a painful 
constriction,  which  depends  upon  contraction  of  the  diaphragm. 
Some  patients  retain  their  consciousness  and  intellectual  faculties 
throughout  the  paroxysm ; others,  on  the  contrary,  lose  them  only 
for  a few  moments ; whilst,  in  some,  their  functions  are  suspended 


526 


HYSTERIA. 


until  the  attack  is  completely  over.  Different  parts  of  the  body  are 
often  the  seats  of  very  acute  pain.  Some  women  say  that  it  seems 
to  them  as  though  the  head  were  squeezed  in  a vice  or  broken  by 
the  blows  of  a hammer ; others  complain  of  violent  epigastric  pain, 
and  of  terrible  cramps  and  anguish  about  the  region  of  the  heart. 

Though  it  most  frequently  happens  that  the  action  of  the  senses 
and  of  the  intelligence  is  momentarily  enfeebled  or  even  suspended, 
it  nevertheless  happens,  in  some  cases,  that  the  sensitive  faculties  are 
extremely  developed  ; indeed,  hysterical  women  have  been  observed, 
in  whom  the  senses  of  smell,  touch,  sight  and  hearing  were  more 
delicate  during  the  attack  than  in  a state  of  health,  and  who  hear  all 
that  is  said,  even  in  a low  tone,  and  see  all  that  passes  about  them. 
Amongst  such,  are  some  who  answer  questions  addressed  to  them ; 
others,  on  the  contrary,  cannot  speak,  but  indicate,  with  the  hand, 
what  they  suffer,  and  after  the  paroxysm,  describe  all  that  they  have 
heard,  seen  and  felt,  without  omission  of  the  slightest  circumstance. 
Often,  after  these  various  symptoms,  a period  of  quiet  occurs,  which 
leads  to  the  belief  that  the  paroxysm  has  reached  its  termination.  If 
we  interrogate  the  patient  on  this  point,  she  answers,  without  ever 
scarcely  deceiving  herself,  that  it  is  or  is  not  terminated.  In  fact, 
so  long  as  the  patient  fails  to  assert  that  the  paroxysm  has  passed, 
the  symptoms  generally  reappear:  it  is  rare  that  women  deceive 
themselves,  even  in  their  first  attack ; and,  d fortiori , when  they 
have  already  had  several.  We  will  add,  that  in  the  most  marked 
cases,  the  patients,  from  the  opening  of  the  attack,  utter  piercing, 
rapid  cries,  which  have  something  peculiar  in  them,  and  which  leads 
us  at  once  to  recognize  the  disease,  if  we  have  already  had  occasion 
to  observe  it. 

After  each  violent  fit,  there  is  commonly  an  emission  of  inodorous 
gas  from  the  mouth,  preceded  by  noisy  borborygmi,  and  accompanied 
by  vomiting.  The  respiration  is  high,  frequent,  laborious  and  inter- 
rupted, and  sometimes  seems  to  cease,  even.  The  pulsations  of  the 
heart  are  generally  tumultuous,  hurried  and  painful.  The  state 
of  the  pulse  is  very  variable  ; it  is  small,  contracted,  frequent,  irregu- 
lar, and,  in  some  cases,  effaced  by  the  convulsive  movements  of  the 
muscles  and  the  subsultus  of  the  tendons.  We  ought,  however,  to 
remark,  that  the  arterial  pulsations  differ  according  to  the  region  of 
the  body ; for  even  when  the  pulse  presents  the  different  modifica- 
cations  we  have  just  mentioned,  the  carotids  beat  with  vehemence, 
and  the  jugular  veins  are  felt  to  be  very  much  enlarged.  The  patient 
often  feels  an  acute  and  poignant  pain  in  a fixed  and  circumscribed 
portion  of  the  head,  which  authors  have  designated  under  the  title 
of  clavus  hystericus.  In  some,  expectoration  is  frequent,  and  some- 
times the  saliva  is  even  slightly  frothy,  but  without  froth  in  the 
mouth.  These  different  phenomena  are  accompanied  by  noise  in  the 
ears,  by  vertigo,  confusion,  the  sensation  of  dazzling  and  sparks, 
which  float  before  the  eyes,  or  a kind  of  thick  mist,  which  impairs 
and  sometimes  entirely  obscures  vision.  Most  of  the  patients  utter 
frightful  cries  and  howls,  which  can  be  compared  only  to  those  of  the 
wolf  j they  abandon  themselves  also  to  immoderate  laughter,  alter- 


HYSTERIA. 


527 


nating  with  sobs  and  tears.  These  last  symptoms,  which  are  often 
the  precursors  of  an  attack,  also  show  that  the  fit  is  approaching  its 
termination.  We  ought  to  add  that,  while  in  the  greater  number  of 
cases,  the  patient  continues  panting,  and  agitated  at  the  slightest  noise 
or  shock,  during  the  remission  of  the  symptoms,  it  sometimes  hap- 
pens that  she  remains  immovable,  as  though  in  a kind  of  ecstacy  or 
somnambulism. 

When  the  hysteric  paroxysm  has  passed  through  all  its  periods, 
the  patient  regains  the  use  of  her  intellectual  and  sensitive  faculties; 
she  opens  her  eyes,  and  utters  deep  sighs  and  plaintive  moans ; the 
action  of  the  different  functions  is  re-established  little  by  little  ; the 
pulse  becomes  soft,  undulating  and  regular ; the  respiration  assumes 
its  normal  rhythm;  a gentle  warmth  and  moisture  appear  upon  the 
surface;  the  neck  of  the  womb,  the  vagina  and  vulva,  which  were 
dry  and  spasmodically  contracted  during  the  paroxysm,  then  become 
more  dilatable  and  are  lubricated  by  an  abundant  secretion:  finally, 
after  the  paroxysm,  which  commonly  terminates  by  involuntary 
tears,  by  sardonic  laughter,  by  eructations,  and  sometimes  by  press- 
ing desire  to  expel  the  urine,  which  is  abundant  and  limpid,  there 
remains  nothing  but  a sensation  of  fatigue  in  the  limbs,  and  a sort  of 
general  lassitude  and  despondency. 

As  each  of  the  morbid  phenomena  we  have  just  described,  may 
be  either  very  mild  or  very  severe  at  different  periods,  whether 
in  the  same  patient,  or  in  different  persons,  we  regarded  it  as  useless 
to  divide,  as  has  generally  been  done  up  to  the  present  time,  the 
progress  of  the  symptoms  into  different  stages,  which,  not  being 
precise,  would  render  any  limitations  we  might  assign  to  each  degree 
of  the  hysterical  attack  arbitrary  and  inexact.  We  must  inform  our 
readers,  also,  that  we  deem  it  best  to  dispense  with  treating,  at 
present,  of  two  other  forms  of  spasmodic  disorder,  which  we  shall 
speak  of  hereafter,  as  we  desired  to  separate  them  altogether  from 
hysteria,  with  which  they  are  often  associated,  but  from  which  they 
differ  in  several  essential  characters.  From  careful  study,  and  ana- 
lysis of  the  symptoms  at  the  bed-side  of  the  patient,  we  have  been 
led  to  conclude,  that  the  spasmodic  affections  to  which  we  refer,  and 
which,  like  hysteria,  are  not  confined  exclusively  to  the  female , 
though  by  far  the  most  frequenrin  them,  emanate  from  two  primary 
sources,  to  wit : the  encephalon,  and  the  stomach  and  upper  part  of 
the  intestines.  In  order  to  establish  a more  rational  system  for  the 
application  of  remedial  agents,  and  still  more  to  introduce  more 
correct  language,  and  avoid  confusion  of  ideas,  we  designate  these 
lesions,  which  have  been  improperly  considered  as  varieties  of  hys- 
teria, by  terms  which  suggest  at  the  same  time  their  nature,  and  the 
viscera  which  we  suppose  to  be  primarily  affected : they  are  cere- 
hrospasm  and  gastrospasn\ , which  we  shall  treat  of  after  concluding 
our  remarks  upon  hysteria,  properly  so  called,  or  metrospasm. 

The  symptoms  of  hysteria,  as  we  have  just  said,  do  not  always 
present  the  same  degree  of  intensity.  Sometimes  the  attacks  are  very 
slight,  and  limited  to  constriction  of  the  throat  and  spasmodic  visceral 
movements,  without  the  convulsions  and  other  secondary  symptoms 


52S 


HYSTERIA. 


which  alarm  the  attendants.  It  even  happens,  in  some  cases,  that  cer- 
tain characteristic  signs  do  not  appear,  while  in  others  very  unusual 
phenomena  may  be  observed,  such  as  a desire  to  bite,  hydrophobia, 
frequent  hiccough,  etc.  The  duration  of  the  paroxysms,  also,  is  very 
irregular;  they  vary  from  a few  moments  to  one  or  two  hours,  or 
even  days.  The  epoch  of  the  attacks,  also,  is  almost  always  uncer- 
tain ; nevertheless,  they  have  been  observed,  in  certain  cases,  to  recur 
in  a periodical  or  intermittent  manner.  Their  number,  likewise, 
is  very  variable  ; while  some  persons  are  subject  to  them  every 
week  only,  or  every  month  or  two,  others,  again,  have  them  once, 
or  even  several  times  a day  ; we  ought  to  state,  moreover,  that  the 
attacks  diminish  in  violence  and  frequency  with  the  progress  of  age. 
During  the  interval  between  the  paroxysm,  the  health  seems  to  be 
perfect ; some  patients,  not  only  preserve  their  embonpoint,  but  even 
become  fatter  and  fresher.  In  the  greater  number  of  cases,  however, 
hysterical  women  feel  a sort  of  painful  tension  about  the  pelvic 
cavity,  and  wear  upon  their  features  a dejected  expression,  which  is 
augmented  by  a constant  leucorrhoea. 

The  termination  of  hysteria  is  preceded  by  a progressive  dimi- 
nution in  the  number  and  violence  of  the  attacks,  but  we  cannot  rely 
upon  the  entire  disappearance  of  the  disease,  until  the  patient  has 
been  well  for  several  years.  If  we  fail  to  remove  the  predisposing 
and  occasional  causes,  and  especially  if  the  hygienic  and  pharma- 
ceutical treatment  be  badly  directed,  the  disease  continues  to  ad- 
vance ; it  becomes  rebellious  to  all  curative  means  that  may  be 
opposed  to  it,  and  may  be  indefinitely  prolonged,  unless  it  degene- 
rates into  different  lesions,  which,  by  their  progress,  shorten  the  term 
of  life.  The  principal  diseases  which  may  follow  or  complicate 
hysteria  are : hypochondriasis,  epilepsy,  chronic  metritis,  amenor- 
rhoea,  nymphomania,  and  all  the  organic  lesions  of  the  uterus  and 
ovaries.  It  is  in  cases  of  this  kind  only,  that  the  disorder  proves  fatal.* 
We  may  add,  that  it  has  sometimes  ceased  spontaneously  after  a 
single  attack,  and  at  other  times  after  many.  It  has  been  known  to  ter- 
minate by  sweating,  by  profuse  leucorrhcea,  by  diarrhoea,  and  finally 
by  the  appearance  of  furunculi,  and  various  cutaneous  eruptions. 
According  to  Georget,  the  cessation  of  the  paroxysms  has  been 
known  to  follow  a sudden  fright. 

When  the  attacks  are  of  long  duration,  and  especially  when  the 
patients  remain  for  a long  period  immovable,  it  so  much  resembles, 
in  certain  cases,  the  appearances  of  death,  that  the  most  unfortunate 
mistakes!  have  resulted  from  it.  In  order  to  avoid  so  unhappy  an 

* In  his  Inaugural  Thesis,  (Paris,  1808,)  Rullier  details  the  interesting  case  of  a 
young  girl,  who  died  from  an  hysterical  affection,  occurring  after  a violent  frightdur- 
ing  the  menstrual  period.  As  this  disease  presented,  in  conjunction  with  the  hyste- 
rical symptoms,  different  phenomena  which  might  be  referred  to  hydrophobia,  such 
as  horror  of  fluids,  inability  to  swallow  drinks,  violent  pain  in  the  throat,  desire  to 
bite,  perfect  integrity  of  the  intelligence,  etc.,  it  cannot  be  affirmed  whether  it  was 
really  due  to  an  uterine  spasm  or  not. 

-f-  The  Journal  des  Savants  for  the  year  1745,  reports  the  case  of  Lady  Russel,  whose 
body  remained  for  eight  days  without  giving  the  slightest  appearance  of  life,  or  the 
least  sign  of  alteration.  This  person,  who  lived  a long  time  alter,  was  aroused  by 


HYSTERIA. 


529 


error,  we  should  follow,  not  only  the  wise  counsel  of  Klein ; pro 
mortuis  habit  x ante  diem  tertiam  terrx  non  sunt  mandandx ; but 
likewise  forbid  the  inhumation  of  hysterical  women  in  a state  of 
apparent  death,  until  the  commencement  of  decomposition  shall  have 
afforded  a certainty  that  a return  to  life  is  impossible. 

The  diagnosis  of  hysteria  is  not  generally  difficult,  though  it  has 
been  mistaken  for  epilepsy,  hypochondriasis,  syncope,  catalepsy  and 
apoplexy.  Several  authors,  amongst  others,  Ch.  Lepois,  Hyghmore, 
Boerhaave,  Sydenham,  Sylvius,  Van-Swieten,  Whytt,  Lorry,  Tissot, 
Pomme  and  Alberti,  confound  hysteria  with  hypochondriasis,  and 
consider  them  to  be  identical  diseases.  Physicians  of  the  present  day 
commonly  agree  in  considering  the  two  affections  as  entirely  differ- 
ent indeed,  the  two  diseases  possess  characters  so  distinctive  as  to 
make  it  impossible  to  confound  them.  Hypochondriasis  rarely  occurs 
before  an  advanced  age,  and  almost  exclusively  in  men,  while  hyste- 
ria often  shows  itself  even  before  the  epoch  of  puberty,  and  never 
affects  others  than  women.  The  latter  disease  always  commences 
by  paroxysms  which,  to  a considerable  extent,  derange  nearly  the 
whole  economy,  whose  functions  are  again  executed  as  in  a state  of 
health,  as  soon  as  the  attack  is  over;  in  hypochondriasis,  the  invasion 
is  slow  and  gradual,  and  the  chief  characters  of  the  disease  are  to  be 
found  in  the  induction  of  derangements  of  the  digestive  functions,  in 
its  being  continuous,  or  presenting  only  slight  remissions,  and  finally 
in  its  giving  an  unsound  direction  to  the  ideas.  Moreover,  in  the  last- 
named  affection,  we  do  not  find  the  spasmodic  and  convulsive  con- 
tractions, and  especially  the  weeping,  laughter, sighing;  the  expulsion 
of  inodorous  gases,  or  the  eructations  which  precede  the  close  of  the 
paroxysms  in  hysterical  patients.  Besides,  after  death  in  persons 
who  have  perished  from  hysteria,  we  rarely  meet,  as  in  hypochon- 
driasis, with  extensive  visceral  alterations,  especially  of  the  stomach, 
intestines,  liver,  and  spleen. 

the  sound  of  the  bells  of  a neigbouring  church,  whilst  her  husband,  who  vehemently 
opposed  her  inhumation,  was  holding  her  hand  and  bathing  it  with  his  tears.  Joseph 
Raulin,  ( Traite  des  affect,  vapor.  1758,)  speaks  of  an  hysterical  girl,  whose  funeral  he 
postponed,  because  her  colour  had  not  entirely  changed.  The  author  adds,  that  in 
the  course  of  a few  hours  the  supposed  corpse  recovered  her  consciousness.  A.  Pare, 
(liv.  xiv.  p.  992,  chap.  54,)  says,  that  a celebrated  anatomist,  “ lequel  estant  pour  lors 
resident  en  Espagne,  fut  mande  pour  ouvrir  une  femme  de  maison,  qu’on  estimait 
estre  morte  par  une  suffocation  de  matrice.  Le  deuxieme  coup  de  rasoir  qu’il  donna, 
commen§a  la  dite  femme  d se  monvoir  et  demontrer  qu’elle  vivait  encore.”  This 
mistake,  which  was  made  in  1564,  by  Vesalius,  who  was  invited  to  the  court  of  Spain 
by  Charles  the  Fifth,  gave  rise  to  a criminal  proceeding  against  that  illustrious  ana- 
tomist, who  was  condemned  by  the  Holy  Inquisition,  to  an  ignominious  punishment, 
which  the  king,  Philip  II.,  commuted  to  a pilgrimage  to  the  Holy  Land.  We  ought 
to  say,  that  those  conditions  of  protracted  apparent  death,  of  which  Aretaeus,  Aetius, 
Diogenes  Laertius,  Pliny,  the  naturalist,  J.  M.  Lancisi,  etc.,  cite  examples,  are  ex- 
tremely rare,  particularly  after  attacks  of  hysteria. 

* M.  Dubois,  of  Amiens,  of  all  authors,  whether  ancient  or  modern,  is  the  one  who 
has  best  pointed  out  the  differences,  and  distinctive  characters  of  hysteria  and  hypo- 
chondriasis. The  labours  of  this  young  and  able  physician,  which  have  been 
crowned  by  the  Royal  Society  of  Medicine  of  Bordeaux,  deserve  this  honourable  dis- 
tinction on  every  account,  from  the  judicious  criticism,  the  philosophical  arguments, 
and  the  vast  erudition  which  they  display.  The  work  of  M.  Dubois,  is  entitled : 
Histoire  philosophique  de  l' hypochondrie  et  de  I'hysterie , 1837. 

34 


530 


HYSTERIA. 


Epilepsy  differs  from  hysteria  in  several  strongly-marked  particu- 
lars. In  epilepsy  there  are  sudden  loss  of  consciousness  and  complete 
suppression  of  the  action  of  the  senses;  the  face  is  always  of  a deep 
red,  violet  or  livid  colour ; the  saliva  escapes  from  the  mouth  and 
forms  froth  upon  the  lips.  The  pulse  is  strong  and  accelerated,  the 
respiration  accompanied  by  loud  and  jerking  rhonchus : the  eyes  are 
turned  upwards,  convulsed,  deadened  and  protruding;  the  pupils 
dilated,  and  the  lips  hideously  swollen  ; finally,  the  aura  epileptica 
seems  to  arise  in  some  point  or  other  of  the  body,  generally  in  one 
of  the  fingers  or  toes,  and  simultaneously  with  these  symptoms, 
which  are  absent  in  hysteria,  occur  convulsive  movements,  ordina- 
rily more  violent  upon  one  side  than  the  other,  and  chiefly  affect- 
ing the  muscles  of  the  trunk  and  face.  Besides,  in  epilepsy,  we 
never  observe  the  sighs,  cries,  sobs,  tears,  explosions  of  laughter, 
the  sensations  of  strangling,  and  the  globus  commencing  in  the  hy- 
pogastrium,  as  we  do  in  hysteria.  These  distinctive  characters  were 
pointed  out  long  since.  Celsus  (lib.  iv.  cap.  xx.,)  traced  them  in  a 
concise  and  exact  manner,  when  he  said,  “ neque  oculi  vertuntur, 
nec  spumse  projluant,  nec  nervi  distenduntur , sopor  tanturn  est.” 
Cselius  Aurelianus,  who  was  the  cotemporary  nearly  of  Galen,  in 
speaking  of  the  differences  between  epilepsy  and  hysteria,  thus  ex- 
presses himself:  “ Frequenter  simile  pati  epilepticis  et  d matricis 
prsefocatx  mulieres  inveniuntur  ; siquidem  non  aliter  sensibus 
privantur , sed  discernantur  quod  in  ultima  accessionis  parte  per 
os  atque  nares  spurn  arum  Jluore  non  afficiantur .”  (De  morb. 
acut.,  lib  2.) 

Syncope  differs  from'  hysteria  in  the  complete  cessation  of  the  pul- 
sations of  the  heart  and  arteries  ; in  the  paleness  of  the  face  ; the  icy 
coldness  of  the  extremities;  the  absence  of  convulsive  movements, 
and  the  short  duration  of  the  attack,  which,  if  prolonged,  would 
produce  inevitable  death. 

Apoplexy  may  be  distinguished  from  uterine  spasm,  by  the  para- 
lysis of  one  half  of  the  body,  or  of  a limb ; by  that  of  the  tongue  ; 
by  the  distortion  of  the  mouth ; by  the  remarkable  fulness  of  the 
pulse  and  great  difficulty  of  respiration,  accompanied  by  a kind  of 
snoring.  These  different  phenomena  are  not  met  with  in  hysteria. 

Finally,  in  catalepsy , the  eyes  are  open  and  fixed,  the  limbs 
are  stiffened  and  immovable,  and  retain  the  position  they  were  in  at 
the  moment  of  the  attack.  If  the  paroxysm,  however,  is  not  a severe 
one,  the  limbs  may  be  flexed  or  extended,  but  even  then  retain  the 
attitude  which  is  given  to  them. 

It  sometimes  happens  that  females  have  some  motive  that  leads 
them  to  simulate  hysterical  paroxysms,  either  to  induce  the  belief 
that  they  have  been  maltreated,  to  obtain  the  consent  of  their  parents 
to  a union  which  they  desire,  or  to  protract  their  stay  in  a hospital,  or 
to  obtain  assistance  from  the  attendants,  etc.  Should  we  suspect  them 
of  malingering,  we  may  avoid  being  duped  by  the  trick,  by  inform- 
ing ourselves  first  of  the  persons  around  the  patient,  whether  she  has 
any  motive  for  feigning  disease  ; we  should  then  study  the  symptoms 
attentively,  and  during  both  the  paroxysms  and  the  intervals,  ques- 


HYSTERIA. 


531 


tion  the  woman,  in  order  to  discover  whether  she  does  not  experience 
some  phenomena  incompatible  with  those  she  presents,  and  which 
are  essential  to  the  nature  of  the  disease.  We  should  endeavour  to 
make  her  contradict  herself;  finally,  we  almost  always  feel  certain 
that  the  attacks  are  simulated,  if  the  patient  refuse  to  submit  to  treat- 
ment, because  really  hysterical  persons  are  generally  importunate 
for  the  prescription  of  remedies  fit  to  remove  their  disorder.  It  is 
proper  to  remark,  also,  that  we  should  avoid,  with  the  greatest  care, 
showing  the  slightest  doubt  as  to  the  reality  of  the  disease ; for,  in 
case  it  truly  exists,  not  only  is  the  patient  exceedingly  affected  by 
the  doubts  she  is  allowed  to  perceive,  but  her  condition  is  almost 
always  aggravated  thereby. 

The  prognosis  of  hysteria  depends  upon  an  infinitude  of  circum- 
stances ; yet,  it  is  not  usually  regarded  as  dangerous,  and  persons 
are  astonished  to  see  the  most  frightful  symptoms,  and  a species  of 
agony,  so  to  speak,  give  place  in  a few  moments  to  perfect  calm,  and 
all  the  signs  of  health.  Indeed,  the  disorder  is  more  alarming  than 
dangerous ; wherefore,  Sennertus  ( Prax . Med.,  lib.  iv.,  1632,)  says,  in 
speaking  of  hysteria  : “ Malum  quidem  plerumque  feminis  lethale 
non  est ; ” nevertheless,  he  adds,  “ aliquando  tamen , superveniente 
syncope , aut  gravibus  convulsionibus  aut  calore  nativo  extincto , 
segrss  £ vi/a  tolluntur The  same  prognosis  was  made  by  Riviere, 
who  followed  Sennertus,  step  by  step,  and  often  copied  without  citing 
him;  this  author  thus  expresses  himself  in  his  treatise,  [Prax.  Med., 
lib.  xv.,  cap.  6,  1640) : Raro  hie  affect  us  inter ficit  segrot  antes.  In 
his  dissertation,  ( De  malo  hysterico,)  Frederick  Hoffmann,  like  the 
authors  we  have  just  cited,  has  presented  a not  very  unfavourable 
prognosis,  when  he  said  : “ Vera  passio  hysterica,  ut  valde  dira  et 
terribilis  videatur,  in  se  non  adeo  periculosa  sit.”  When  the  dis- 
ease is  recent,  especially  if  the  person  be  young  and  not  very  irrita- 
ble, if  the  determining  cause  be  a transitory  one,  or  if  it  is  capable 
of  being  removed;  or  finally,  if  the  attacks  take  place  at  some  distance 
of  time  from  each  other,  and  are  of  short  duration,  and  if  all  the 
functions  are  properly  executed  during  the  intervals,  it  is  almost  cer- 
tain that  an  entire  cessation  of  the  attacks  will  take  place  before  long. 
On  the  contrary,  where  the  female  is  aged,  and  of  feeble  and  very 
irritable  constitution;  where  the  attacks  are  frequent,  of  long  duration, 
and  accompanied  by  violent  symptoms,  the  treatment  will  be  long, 
and  the  cure  doubtful ; though  we  ought  not  to  despair  of  effecting 
it.  The  prognosis  is  likewise  rather  unfavourable  when  the  hysteria 
is  complicated  with  epileptic  symptoms,  which  have  the  additional 
inconvenience  of  frequently  obscuring  the  diagnosis.  Should  the 
disease  seem  to  be  connected  with  some  chronic  irritation,  or  organic 
alteration  of  the  uterus  and  ovaries,  the  affection,  which  would  then 
be  secondary,  would  require  a prognosis  relative  to  that  of  the  pri- 
mary disease.  Nevertheless,  in  certain  cases  where  hysteria  seemed 
to  depend  upon  amenorrhoea,  or  some  derangement  of  the  menstruse, 
the  hysterical  symptoms  have  been  known  to  continue  with  the  same 
violence,  even  after  the  menstrual  flux  has  been  re-established  and 
regulated.  The  same  has  been  observed  in  regard  to  suppression  of 


532 


HYSTERIA. 


the  lochia,  which,  like  that  of  the  menstruae,  is  perhaps  as  often  the 
consequence  as  the  cause  of  the  affection  that  forms  the  subject  of  this 
chapter.  The  slight,  and  nearly  permanent  spasmodic  state,  desig- 
nated by  M.  Louyer-Villermay,  hystericism , and  which  commences 
chiefly  by  a peculiar  sensation  of  constriction  in  the  throat,  and  a sort 
of  general  malaise  experienced  by  some  women  whose  menstruation 
is  difficult,  or  who  are  affected  with  an  uterine  lesion,  constitutes  a 
secondary  phenomenon  not  deserving  of  our  attention,  except  as 
being  a pathognomonic  sign.  It  suffices  to  say,  that  the  spasm  con- 
fined to  the  uterus  alone,  is  commonly  of  short  duration,  and  seldom 
appears  except  during  the  flow  of  the  menses,  or  a few  days  before 
their  appearance. 

The  treatment  of  hysteria  presents  two  fundamental  indications  : 
una  in  paroxismos , altera  extra  paroxismum , say  Sennertus  and 
Riviere.  The  first  indication  consists  in  acting  during  the  attack  so 
as  to  diminish,  as  far  as  possible,  its  force  and  duration ; the  second, 
in  preventing  during  the  interval  a renewal  of  the  attack  by  combat- 
ing the  disease  itself,  that  is  to  say,  by  seeking  to  destroy  the  action 
of  its  causes,  effects,  and  complications. 

In  treating  the  paroxysms,  and  with  a view  to  shorten  their  dura- 
tion, we  must,  above  all,  observe  the  precaution  of  taking  off  the 
clothes  and  removing  every  thing  binding,  as,  for  example,  corsets, 
girdles,  garters  and  collars,  which  embarrass  both  the  respiration  and 
circulation,  and  obstruct  the  motions  of  the  neck  and  thoracic  and 
abdominal  cavities.  We  should  then  make  the  patient  lie  down  on  a 
bed  or  large  couch,  taking  care  to  arrange  her  with  the  head  higher 
than  the  trunk  and  inferior  extremities,  and  to  confine  her  so  that  she 
may  not  strike  her  head,  wound  herself  in  any  way,  tear  her  hair,  bite 
herself,  or  be  exposed  to  falling.  When  the  attack  is  violent,  it  will 
require  at  least  four  persons  to  hold  her  limbs,  whose  movements 
should  be  followed  without  being  entirely  prevented,  for  the  more 
closely  the  patients  are  confined,  the  more  exhausted  and  fatigued 
are  they  when  the  attack  is  over.  In  hospitals  a straight  jacket  is 
used,  which  alone  suffices  to  secure  the  patient;  but  we  ought  to 
observe  that  this  apparatus  seems  to  have  something  in  it  humiliating 
to  them,  and  affects  them  painfully  and  unfavourably.  During  the 
attack  visitors  should  be  excluded,  leaving  those  persons  only  in  the 
room  whose  aid  and  presence  are  indispensable:  it  is  also  very  im- 
portant to  avoid  making  remarks  aloud  upon  the  state  of  the  patient, 
as  this  may  irritate  or  alarm  her ; for,  very  often,  in  the  strongest 
paroxysm,  she  does  not  entirely  lose  the  use  of  her  senses,  but  hears 
perfectly  all  that  is  said  around  her. 

To  abate  the  violence  of  the  attack  and  shorten  its  duration,  the 
patient  should  be  freely  exposed  to  the  air,  and  made  to  respire 
strong  and  penetrating  odours,  as  ether,  acetic  acid,  liquid  ammonia 
or  the  heated  vapours  disengaged  from  quills,  horn,  old  leather  or 
wool  thrown  upon  burning  coals.  We  have  employed,  with  some 
advantage,  fomentations  or  lotions  of  a mixture  of  eight  parts  of  water 
to  one  of  Cologne-water  or  vinegar,  applied  to  the  temples  and  fore- 
head. Small  enemata  of  cold  water,  especially  with  the  addition  of 


HYSTERIA. 


533 


three  grains  of  camphor  and  eight  or  ten  of  assafoetida  suspended  in 
the  yolk  of  an  egg,  and  from  fifteen  to  twenty  drops  of  Sydenham’s 
laudanum,  have  always  appeared  to  us  to  produce  good  effects, 
especially  where  the  attack  is  mild  and  the  spasm  in  some  sort  concen- 
trated upon  the  organs  contained  within  the  pelvis.  A means  which 
often  serves  to  arrest  an  attack,  consists,  when  we  can  separate  the 
jaws,  in  the  introduction  into  the  mouth  of  a tablespoonful  of  very 
cold  water,  to  which  has  been  added  two  or  three  drops  of  ammonia. 
We  have  also  used  with  good  effect,  the  following  potion : R — distilled 
water  of  balm,  three  ounces ; orange-flower  water,  one  ounce  ; syrup 
of  valerian  and  poppy-heads,  each,  one  ounce  ; tincture  of  musk  and 
castor,  each,  twenty  drops ; sulphuric  ether,  fifteen  drops.  Mix  and 
give  at  first  two  tablespoonfuls  at  once,  and  then  one  every  hour. 

In  -very  violent  attacks,  it  is  well  to  employ  dry  or  stimulating 
frictions  of  the  whole  body,  and  particularly  of  the  limbs  and  verte- 
bral column  ; the  last  may  be  made  of  camphorated  alcohol,  or  still 
better  of  the  following  liniment : R.  olive-oil,  two  ounces ; camphora- 
ted alcohol  and  spirits  of  turpentine,  each  one  ounce ; liquid  ammonia 
and  Sydenham’s  laudanum,  each  one  drachm.  To  the  employment  of 
these  measures  may  be  added  dry  cups,  and  especially  flaxseed  poul- 
tices sprinkled  with  mustard,  and  applied  to  the  hypogastric  region, 
to  the  thighs,  and  even  to  the  arms.  Should  the  symptoms  be  very 
intense,  pure  mustard,  and  even  Gondret’s  ointment  may  be  used.* 
Though  several  authors  speak  of  having  seen  hysterical  paroxysms 
quelled  by  bleeding,  we  think  that  it  ought  not  to  be  resorted  to  except 
when  the  female  is  either  plethoric  or  irregular  in  her  menstruae,  or 
when  she  is  threatened  with  congestion  of  some  important  organ  ; for 
we  have  known  it  to  increase  the  intensity  and  frequency  of  the  at- 
tacks ; should  the  latter  return  at  certain  hours,  and  be  preceded  by 
premonitory  signs,  we  should  endeavour  to  prevent  their  return  by 
the  use  of  some  of  the  means  just  mentioned,  and  especially  by  irri- 
tating pediluvia  and  the  application  of  sinapisms  to  the  thighs. 

Amongst  the  great  number  of  remedies  that  have  been  brought  for- 
ward for  the  purpose  of  arresting  hysterical  paroxysms,  we  may  cite 
narcotic  injections!  and  antispasmodic  suppositories  introduced  into 
the  vagina;  aromatic  or  fetid  fumigations  of  the  genital  parts;  a 
sudden  jet  of  cold  water  upon  the  face ; and  also,  for  the  purpose  of 
suddenly  arresting  the  fit,  by  a violent  shock,  some  have  made  use 
of  reproaches,  or  of  threats,  and  of  the  most  indecent  manoeuvres. 
The  precept  of  the  father  of  medicine : Nubat  ilia  et  morbxnn  ejfa- 
giet , has  led  to  the  proposal  of  consummating  the  venereal  act  during 
an  attack  of  hysteria ; Duret  {In  enarrat.  ad , etc.,  cap.  59),  speaking 
of  a husband,  thus  expresses  himself:  Jussi  ut  rem  cum  uxore  sua 
haberet : rem  habuit , indlque  statim  convaluit.  iEtius,  also, 

* Made  by  mixing  together  an  ounce  of  suet  and  lard;  and  two  ounces  of  liquid 
am  mon  i a. — Trans. 

f Bichat  successfully  treated  three  hysterical  girls  by  means  of  injections  which  he 
caused  to  be  retained  in  the  vagina,  and  to  which  he  added  from  one  hundred  to  one 
hundred  and  fifty  drops  of  laudanum. 


534 


HYSTERIA. 


tells  us  of  a practice  which  was  employed  with  the  same  view  by 
certain  matrons : (s Excrelo  multo  crasso  viscosoque  semine  ex  digi- 
torum  contrectatione”  etc.  A Pare  says  in  his  unaffected  style  (lib. 

24,  chap.  55,)  “A  plusieurs  d’icelles il  s’evacne  dehors  une 

grosse  sentence principal ement  cl  celles  d qui  les  matrones  titil- 

lent  le  col  de  leur  rnatrice Finally,  Jerome  Capivaci  (Med.  pr act. 
lib.  iv.  Be  morh.  mulier,)  dares  to  give  still  more  extraordinary  and 
indecent  advice ; this  idea,  destructive  of  both  morals  and  health, 
ought  always  to  be  rejected  with  horror,  notwithstanding  the  opinion 
of  Sauvages,  who  speaks  of  a woman  in  whom  “clitoridis  titillatio 
a barhi-tonsore  impudico  instituta  paroxysmum  solvebat .”  To 
prove  the  falsity  of  the  doctrines  upon  which  the  immoral  practices 
we  have  just  mentioned  repose,  it  is  sufficient  to  state  that  there  are 
at  least  as  many  hysterical  persons  in  houses  of  prostitution  as  in 
convents,  and  that  married  women  are  more  exposed  than  virgins, 
to  uterine  spasm.  Far  from  calming  the  attack,  coitus,  which  is  the 
most  direct  excitant  of  the  uterine  system,  could,  in  general,  only  in- 
crease its  violence. 

Though  the  treatment  of  hysteria  during  the  paroxysm  may  be 
almost  purely  empirical,  that  which  we  ought  to  employ  during  the 
intervals,  that  is  to  say,  the  radical  treatment  cannot  be  successful 
unless  it  assume  as  its  first  principle  the  removal  of  the  cause  of  the 
disease,  nor  unless  it  is  based  upon  the  nature  of  that  same  cause. 
Thus,  if  the  hysteria  co-exist  with  amenorrhoea,  we  must  endeavour 
to  restore  the  menses  by  the  means  pointed  out  in  the  chapter  de- 
voted to  menstrual  suppression : if,  on  the  contrary,  the  attacks  occur 
at  the  moment  of  the  periodical  discharge,  we  must  try  to  prevent 
them  by  the  use  of  baths,  by  emollient  drinks,  by  antispasmodic  and 
narcotic  enemata,  and  by  small  revulsive  bleedings  between  each 
menstrual  epoch.  The  same  plan  should  be  followed,  if  the  uterine 
spasm  coincide  with  engorgement  of  the  neck,  the  state  of  which 
ought  always  to  be  ascertained  (at  least  in  women  who  have  had 
sexual  intercourse),  before  commencing  the  curative  treatment. 

For  the  purpose  of  combating  the  spasm  itself  and  preventing  the 
return  of  the  paroxysms,  recourse  has  been  had  to  a great  variety  of 
therapeutical  agents,  principally  antispasmodies,  narcotics,  tonics, 
antiphlogistics  and  revellents.  The  antispasmodies  which  have  been 
most  frequently  employed  with  advantage,  especially  in  very  irritable 
persons,  and  those  of  exquisite  sensibility,  are  : the  distilled  waters  of 
balm,  mint,  cherry-laurel,  orange-flowers,  linden-flowers,  and  peony: 
infusions  of  valerian,  mug  wort  and  chamomile ; musk,  castor  and 
assafoetida,  in  tincture  or  substance  ; amber,  camphor,  myrrh,  frank- 
incense, gum  ammoniac,  spiritus  mindereri,  carbonate  and  muriate  of 
ammonia,  Dippel’s  animal  oil,  the  ethers,  syrup  of  ether,  Hoffman’s 
anodyne,  and  finally,  the  oxides  of  zinc  and  bismuth,  and  the  car- 
bonate of  potash ; these  different  remedies,  which  are  administered 
either  in  draughts,  in  the  form  of  enema,  in  pills,  or  by  friction,  are 
often  usefully  combined  with  the  preparations  of  opium,  cicuta, 
hyoscyamus,  aconite  and  lactuca  virosa ; we  ought  to  remark  further 


HYSTERIA. 


535 


that  narcotics*  prescribed  alone,  and  the  medicinal  prussic  acid  even, 
in  the  dose  of  one  or  two  drops  daily  in  an  ounce  of  water,  have 
sometimes  produced  favourable  results. 

Where  the  patient  is  of  a broken  constitution,  thin,  feeble  and 
cachectic ; when  she  is  badly  regulated ; if  she  has  lost  much  blood, 
or  if  she  inhabits  a low,  damp,  badly  ventilated  and  marshy  situa- 
tion, great  advantages  may  often  be  obtained  from  the  employment 
of  tonics;  such  as  the  preparations  of  iron;  cinchona;  rhubarb; 
gentian;  and  infusions  of  the  lesser  centaury  and  Virginia  snakeroot. 
If,  on  the  contrary,  the  patient  were  strong,  plethoric,  very  fat,  and 
especially  if  she  were  at  the  same  time  affected  with  amenorrhoea  or 
dysmenorrhoea,  we  should  resort  to  general  bleeding,  to  scarified  cups, 
and  to  applications  of  leeches  to  the  thighs,  which  at  the  same  time 
act  as  derivatives.  General  baths ; vapour  baths ; hip-baths ; pedi- 
luvia ; emollient  and  sedative  drinks ; broth  made  of  veal,  chicken 
or  frogs ; whey ; milk  diet ; poultices  to  the  hypogastrium ; enemata 
and  injections  of  olive  oil,  regarded  as  specifics  by  Pomme  and  Pres- 
savin ; and,  finally,  all  the  means  capable  of  producing  general  and 
local  relaxation,  are  proper  in  cases  where  hysteria  seems  to  depend 
upon  a state  of  plethora. 

Revellents  are  indicated  chiefly  in  women  of  lymphatic  or  lym- 
phatico-nervous  temperament,  and  sometimes  in  those  who  are  ple- 
thoric; but  they  should  never  be  resorted  to  in  cases  of  the  last 
kind  before  having  first  employed  one  or  more  bleedings.  These 
various  means,  which  comprise  cutaneous  irritants;  sulphurous  dou- 
ches, and  baths  of  the  same  kind;  ammoniacal,  alcoholic,  aromatic 
and  dry  frictions;  sinapisms;  blisters;  setons;  issues;  moxas;  the 
cauterizations  transcurrent es  upon  the  abdomen,  successfully  em- 
ployed by  M.  Lisfranc;  and,  finally,  all  agents  used  with  the  view 
of  displacing  the  morbid  action  of  the  organs  primarily  disordered, 
are  likewise  suitable  when  hysteria  has  followed  an  herpetic,  arthritic 
or  rheumatic  affection.  It  is  for  the  purpose,  also,  of  producing  a 
revulsive  effect,  or  to  remedy  some  gastric  derangement  or  habi- 
tual constipation,  that  purgatives  and  emetics  have  sometimes  been 
advantageously  employed.  Should  the  disease  seem  to  depend 
upon  a state  of  torpor  of  the  genital  organs,  marriage  may  be  recom- 
mended ; while,  if  the  hysterical  attacks  were  dependent  upon  im- 
proper excitation  of  the  genital  organs,  no  hope  of  cure  can  be  enter- 
tained unless  the  manners  are  reformed  and  more  or  less  absolute 
continence  enjoined. 

The  curative  means  we  have  just  mentioned  generally  require  to 
be  employed  with  the  greatest  circumspection,  because  as  the  dis- 
ease is  usually  of  long  duration,  their  abusive  and  protracted  use 
could  not  be  borne  by  the  patients.  It  is  proper  to  remark,  also,  that 
the  action  of  the  therapeutical  agents  cannot  be  followed  by  good 

* We  observe  in  the  11th  vol.  of  the  Revue  Medicate,  p.  31 1,  that  Doctor  Ch.  Coindet 
did  not  hesitate  to  inject  a preparation  of  opium  into  the  veins,  in  a case  of  hysteria 
assuming  the  form  of  tetanus.  The  momentary  success  which  followed  the  employ- 
ment of  this  rash  measure,  did  not  last,  for  the  disease  reappeared  at  the  end  of  six 
weeks. 


536 


HYSTERIA. 


results,  unless  aided  by  dietetic  and  moral  means.  The  regimen  must 
be  modified  according  to  the  constitution  of  the  patient.  Thus,  for 
strong  and  plethoric  persons  should  be  prescribed  a diet  consisting  of 
thin  soups,  milk,  herbaceous  vegetables,  a moderate  use  of  ripe  or 
well-cooked  fruits,  and  some  of  the  white  meats ; those,  on  the  contrary, 
in  whom  feebleness  and  languor  keep  up  extreme  sensibility  of  the 
organs,  should  be  subjected  to  a restorative  diet;  to  the  use  of  nutritive 
aliment,  and  especially  of  the  white  meats  which  are  of  easy  digestion. 
Finally,  a residence  in  some  healthy  situation ; a pure  and  temperate 
air;  walks  in  the  country  in  the  morning  and  evening  during  the  fine 
season^  travelling ; river,  and  especially  sea-bathing ; agreeable  occu- 
pations ; domestic  cares ; useful  and  amusing  reading ; bodily  exer- 
cises ; riding  on  horseback ; means  for  employing  the  mind,  and  select 
society ; such  are  the  moral  and  hygienic  means  capable  of  efficaci- 
ously assisting  the  other  therapeutical  agents,  and  even  of  preventing 
the  development  of  hysteria  in  persons  showing  a predisposition  to 
contract  the  disease.  We  conclude  by  stating  that  those  who  desire 
to  examine  more  thoroughly  the  nature,  seat,  literary  history,  etio- 
logy, and  therapeutical  treatment  of  the  disease  under  consideration, 
would  do  well  to  consult  the  late  works  of  Mess.  Louyer-Villermay, 
Georget,  Ch.  Gerard,  Brachet,  of  Lyons,  Foville,  and  Dubois  of 
Amiens. 


HYSTERIFORM  ATTACKS. 


V 


Though  the  vapoury  or  spasmodic  affections  to  which  women 
are  liable  generally  have  their  point  of  departure  in  the  uterine 
apparatus,  the  analysis  of  the  phenomena  which  constitute  them  and 
of  the  causes  under  whose  influence  they  are  produced,  leaves  no 
doubt  in  our  mind  that  they  may  have  their  source,  either  in  the 
encephalon,  as  supposed  by  Ch.  Lepois,  Willis  and  Georget ; or  in 
the  stomach  and  intestines,  as  supposed  by  Purcel,  Pitciarn,  Hunault, 
Jean  Maria,  Vogel,  Hamilton  and  some  others. 

We  have  one  peremptory  reason  to  prove  that  the  uterus  is  not 
always  the  commencing  point  of  the  spasmodic  affections  of  females, 
which  is,  the  existence  of  hysteriform  paroxysms  in  men,  as  observed 
by  Ch.  Lepis,  F.  Dubois  de  le  Boe,  Morgagni,  Boerhaave,  Raulin, 
F.  Hoffmann,  Pomme,  Leroy,  Cullen,  Haller,  Gardien,  Georget, 
Louyer-Villermay,  Mess.  Recamier,  Trolliet  and  Brachet,  of  Lyons, 
Casimir  Broussais,  and  twice  by  ourselves*  and  by  several  other  phy- 
sicians. Besides,  the  study  of  the  pathogenic  causes,  the  progress  of 
the  disease,  the  analysis  of  the  symptoms  and  their  comparison  with 
those  of  hysteria  properly  so  called,  would  alone  be  sufficient  to 
prove  that  spasmodic  disorders  may  likewise  have,  as  their  primary 
source,  some  particular  irritation  of  the  encephalon  or  stomach. 
Spasm  of  the  former  of  these  organs  or  cerebral  spasm^m^  be  desig- 
nated by  the  title  of  encephalospasm  or  cerebrospasm,  while  we  may 

* We  saw  a case  of  hysteriform  spasm  in  1833,  in  a boy  who  sold  lemonade  in  the 
streets,  and  a second,  a few  days  since  (April  15,  1838),  in  a young  type-founder 
employed  by  M.  J.  Didot. 


HYSTERIFORM  ATTACKS. 


537 


distinguish  spasm  of  the  stomach  under  the  denomination  of  g astro- 
spasm . 

[I  do  not  perceive  the  force  of  the  argument  here  advanced  against  the 
hysterical  nature  and  origin  of  the  hysteric  paroxysm,  or  passion.  Not 
only  the  celebrated  case  mentioned  by  Sydenham,  but  numerous  published 
cases  of  the  disorder  occurring  in  males,  show  that  the  affection  is  not  con- 
fined to  women  alone  ; and  yet,  even  admitting  that  the  womb  itself,  or  the 
ovary,  is  not  at  the  foundation  of  the  malady,  nor  the  disturbing  force  in  the 
malady,  we  may  readily  conceive  it  is  in  the  reproductive  tissue,  and  the 
reproductive  influence  or  power,  that  is  situated  the  fons  et  origo  of  the 
evil.  I conceive  the  question  to  be,  not  so  much  whether  hysteria  arises 
from  a disturbing  power  of  the  womb,  as  from  a disturbing  power  of  the 
reproductive  agencies  implanted  in  the  economy;  and  I conceive  that  devia- 
tions of  that  power,  or  those  agencies,  whether  in  the  male  or  the  female, 
may  alike  be  regarded  as  ipsissimas  causas  in  these  maladies. 

Read,  in  Trousseau  and  Pidoux’s  article,  Medication  Antispasmodique , 
their  exposition  of  the  phenomena  of  the  genital  act,  for  a description  of  the 
hysteriform  state,  in  its  most  exquisitely  marked  features. — M.] 

The  predisposing  causes  of  encephalospasm  independent  of  hyste- 
ria, are : a nervous  temperament ; the  feminine  sex ; the  culture  of 
belles-lettres  and  of  the  arts,  especially  of  poetry ; a vivid  imagina- 
tion ; careful  education ; great  development  of  the  intellect ; habitual 
cephalalgia ; the  abuse  of  perfumes,  of  alcoholic  liquors,  and  of  exciting 
drinks,  especially  coffee ; and,  finally,  all  circumstances  capable  of 
producing  frequent  and  protracted  excitement  of  the  encephalon. 

The  exciting  causes  are : anger ; sudden  fright ; the  unexpected 
receipt  of  bad  news ; the  sight  of  some  painful  spectacle  or  sanguinary 
scene ; the  view  of  another  female  in  a convulsive  paroxysm ; the 
departure  of  some  dearly  loved  person  ; the  sad  impressions  of  me- 
mory, and  strong  and  unexpected  sensations,  as,  for  example,  the 
sound  of  thunder,  of  cannon,  etc. ; a penetrating  odour,  and  espe- 
cially one  for  which  antipathy*  is  felt ; the  hearing  of  certain  pieces 
of  music,  or  of  cries  announcing  imminent  danger ; acute  physical  or 
moral  suffering ; a conflagration,  and  any  great  misfortune,  &c.  We 
attended,  a few  months  since,  a female,  twenty-eight  years  of  age, 
who,  having  previously  suffered  from  nervous  disorders,  was  sud- 
denly taken  with  a violent  paroxysm  of  hysteriform  cerebral  spasm, 
on  seeing  an  only  son,  five  years  old,  fall  from  the  third  story.  M. 
Th  * * *,jr.,  ex-prosector  of  the  Faculte  de  M&decine , fell,  deprived  of 

* M.  Orfila  cites  the  instance  of  a young  lady  who  could  not  be  present  where  a 
decoction  of  flaxseed  was  preparing  without  fainting.  M.  H.  Cloquet  has  observed 
the  same  thing.  Aretaeus  saw  epilepsy  caused  by  certain  odours.  M.  Rostan  says 
that  attacks  of  hysteria,  loss  of  voice,  and  even  suffocation,  have  been  caused  by  the 
colour  of  the  flower  of  the  malva  moschata,  of  the  lobelia  longijlora,  of  the  magnolia 
tripetala. , etc.  We  knew  a lady  who  was  instantly  thrown  into  a nervous  paroxysm 
by  the  smell  of  orange-flowers;  One  of  our  connections,  wife  of  a deputy,  Madame  B. 
de  C * * *,  experienced  the  same  accident  from  the  odour  of  violets.  That  of  the  lily, 
tuberose,  musk,  and  especially  of  frankincense,  often  produces  as  unpleasant  effects, 
not  only  in  women,  but  likewise  in  men. 


538 


hySteriform  attacks. 


consciousness  and  with  convulsive  movements,  at  accidentally  meet- 
ing the  procession  of  the  physician  Cast  in,  on  his  way  to  the  scaffold. 
M.  Brachet,  of  Lyons,  quotes  the  case  of  a washerwoman,  regular  as 
to  her  menses,  and  enjoying  good  health,  who  was  suddenly  attacked 
with  cerebral  spasm,  accompanied  with  loss  of  consciousness,  with 
convulsive  agitation  and  with  a feeling  of  strangulation.  She  had 
let  fall  a bundle  of  linen  that  she  had  just  washed,  while  crossing  the 
shore  plank  of  a boat  used  for  washing.  M.  B * * *,  one  of  the  most 
distinguished  of  our  young  composers,  is  seized  wTith  an  hysteriform 
paroxysm  whenever  he  hears  the  beautiful  finale  of  the  second  act 
of  the  opera  la  Vestale.  Doctor  Vautre  in  his  thesis  cites  the  case 
of  a young  woman,  seventeeen  years  of  age,  who  was  attacked  with 
a cerebral  spasm  as  soon  as  she  heard  the  hour  of  five  strike  on  the 
clock  in  the  apartment ; the  hour  was  that  at  which  her  father  had 
died.  We  could,  were  it  necessary,  quote  a number  of  other  cases 
of  the  same  kind. 

Symptoms. — Like  the  paroxysms  of  hysterical  spasm,  those  of 
cerebral  spasm  appear  suddenly  or  are  preceded  by  a few  prodromes, 
such  as  vertigo,  tinnitus  aunum,  obstinate  insomnia,  absence  of 
mind  and  even  ecstacy,  inability  to  sustain  any  long-continued  intel- 
lectual labour,  and,  finally,  profound  sadness,  alternating  with  exces- 
sive gaiety  and  causeless  laughter.  After  the  precursory  phenomena 
have  lasted  a longer  or  shorter  period  of  time,  the  patient  falls  with- 
out consciousness,  and  loses,  more  or  less  completely,  the  exercise  of 
the  sensitive  and  intellectual  faculties.  This  condition  often  lasts  during 
the  whole  of  the  attack ; nevertheless,  in  some  cases,  the  suspension  of 
the  functions  of  intelligence  is  only  momentary,  and  it  may  happen 
even  that  they  shall  become  more  energetic,  and  the  external  senses 
be  sharpened  and  more  delicate  than  in  the  normal  state.  The 
limbs  and  trunk  are  stiffened  and  affected  as  in  hysteria,  with  con- 
vulsive movements  of  flexion  and  extension ; but  it  is  rare  for  the 
patient  to  complain  of  the  sensation  of  globus  hystericus.  If  the 
last  phenomenon  appears  at  all,  it  commences  in  the  epigastrium 
only : finally,  the  pulse,  the  respiration,  the  heat  and  the  phenomena 
which  precede  the  termination  of  the  paroxysm,  are  nearly  the  same 
as  in  the  attack  of  hysteria.  We  ought  to  remark,  however,  that 
during  the  paroxysm  of  cerebral  spasm,  there  is  rarely  any  disengage- 
ment of  gas  from  the  mouth  and  never  any  borborygmi  and  meteor- 
ism,  as  so  often  seen  in  hysteria.  Cerebrospasm  often  terminates,  after 
a single  spasm,  which  rarely  lasts  more  than  a few  hours ; in  other 
cases,  as  happens  in  hysteria,  it  reappears  a greater  or  less  number 
of  times,  or  is  combined  with  that  affection,  according  as  the  organic 
predispositions  change.  When  the  paroxysms  are  frequently  re- 
newed or  long  protracted,  there  may  follow  loss  of  memory,  mania, 
mental  alienation,  partial  paralysis,  and  strong  tendency  to  apoplexy. 

OF  GASTRO-INTESTINAL  SPASM. 

Gastrospasm  chiefly  attacks  persons  who  make  frequent  use  of 
aromatic  substances,  of  highly-seasoned  salt  and  exciting  dishes,  such 


GASTROINTESTINAL  SPASM. 


539 


as  truffles,  mushrooms,  salt  meat  and  fish,  alcoholic  drinks,  tea, 
coffee,  chocolate  with  vanilla,  etc.  The  frequent  administration  of 
purgatives,  narcotics,  bitters,  astringents,  tonics  and  emetics  also  dis- 
pose to  this  affection.  Nervous  and  melancholy  women,  those  in 
whom  the  stomach  is  feeble,  delicate,  irritable  and  subject  to  nervous 
cramps,  and,  finally,  those  subjected  to  protracted  low  dieting,  are 
likewise  more  liable  than  others  to  gastrospasm. 

The  determining  causes  of  gastrospasm  are  : the  ingestion  of  iced 
drinks,  sherbet,  orgeat  syrup,  or  lemonade  into  the  stomach,  particu- 
larly after  eating;  heavy  and  indigestible  food,  especially  food  for 
which  repugnance  is  felt ; the  administration  of  an  emetic ; a drastic 
purge;  or  some  remedy  whose  perturbing  action  is  very  powerful, 
have  often  given  rise  to  nervous  phenomena,  which  together  consti- 
tute gastrospasm.  M.  Brachet  [toe.  cit.,  p.  135)  relates  the  case  of  a 
lady,  twenty -six  years  old,  who  was  suddenly  taken  with  an  hys- 
terical paroxysm,  after  having  eaten,  without  knowing  it,  of  a dish 
seasoned  with  cheese,  for  which  she  had  a strong  antipathy.  We 
saw,  last  year,  a lady  who  was  generally  regular  and  enjoyed  good 
health,  suddenly  attacked  with  gastrospasm,  after  taking  a few  tea- 
spoonfuls of  vanilla  ice-cream:  we  also  knew  orgeat  syrup,  taken  by 
a lady  thirty-one  years  of  age,  and  tartar-emetic  lotions,  used  by 
another  twenty-three  years  of  age,  to  produce  the  same  effect.  It  is 
proper  to  state  that  these  ladies  were  not  then  at  the  period  of  their 
menstruse,  which  appeared  as  usual,  without  presenting  any  thing 
singular. 

The  prodromes  of  hysteriform  gastrospasm  are,  general  malaise, 
lassitude  of  the  inferior  extremities,  and  sense  of  oppression  at  the 
epigastrium.  To  these  precursory  symptoms,  succeed  intense  gas- 
tralgia,  a kind  of  painful  torsion  and  dragging  pains  in  the  stomach, 
accompanied  by  gurgling  and  by  emissions  of  large  quantities  of 
gas,  with  efforts  at  vomiting  and  sensation  of  constriction  in  the 
throat.  In  this  kind  of  paroxysm,  convulsive  movements  of  the 
limbs,  and  sometimes  general  convulsions,  are  observed  ; the  beating 
of  the  heart  is  strong  and  tumultuous  ; the  respiration  difficult,  inter- 
rupted, loud  and  even  stertorous ; the  face,  which  is  extremely  pale, 
and  particularly  the  region  of  the  stomach,  which  is  the  seat  of  some 
swelling,  are  covered  with  a cold  and  viscid  sweat,  which  is  replaced 
by  a warm,  soft  perspiration,  when  the  paroxysm  approaches  its  ter- 
mination. 

The  persons  most  exposed  to  these  sorts  of  attack,  are  commonly 
subject  to  cramps  of  the  stomach,  to  derangements  of  the  digestive 
functions,  to  chronic  gastritis,  and  to  engorgements  of  the  abdominal 
organs.  These  different  phenomena,  and  the  absence  of  all  nervous 
symptoms  in  the  region  of  the  uterus,  indicate,  in  our  opinion,  with 
sufficient  clearness,  that  such  attacks  have  their  point  of  departure  in 
the  stomach.  It  must  be  evident  that  we  have  devoted  ourselves  to 
the  study  of  the  causes  and  to  the  analysis  of  the  symptoms,  in  order 
to  establish  the  distinction  that  we  have  made,  and  to  discover  the 
different  sources  of  the  spasmodic,  disorders  of  females. 

The  last  variety  of  gastro-intestinal  spasm  yields  either  to  the  em- 


540 


HYSTERALGIA. 


ployment  of  antispasmodics  and  tonics,  or  to  that  of  antiphlogistics, 
local  bleedings,  general  baths,  warm  poultices,  derivatives,  and  espe- 
cially to  frictions  upon  the  epigastrium  with  tartar-emetic.  Cerebral 
spasm  requires  moral  means,  warm  baths,  with  cold  applications  or 
affusions  to  the  head,  leeches  to  the  neck,  and  laxatives,  and  deriva- 
tives to  the  limbs  and  digestive  canal.  We  add,  that  the  employment 
of  these  different  therapeutical  agents  ought  to  be  modified  according 
to  the  causes,  symptoms  and  complications,  and  that  their  use  should 
be  continued  a long  time  after  the  attacks  have  ceased ; that  is  to 
say,  until  the  constitution  shall  have  been  modified  in  such  a way 
that  we  need  no  longer  fear  a relapse.  This  fortunate  result  will  be 
the  more  certainly  attained,  if  the  patient  uses  proper  care  in  avoiding 
the  causes  which  might  bring  on  the  attacks.* 

We  shall  conclude  by  saying,  with  Th.  Willis,  ( Be.  morbis  con - 
vulsiuis,  cap.  x.,  Pathol,  cereb.  et  nerv.,  1667,)  that  the  hysterical 
affection  has  so  bad  a reputation,  ( passio  hysterica  pessimae  adeo 
famae  ex  is  tit,)  that  it  is  made  to  answer  for  every  thing  that  is  trou- 
blesome amongst  women.  When  unable  to  discover  the  cause  and 
treatment  of  any  disorder  which  seems  extraordinary,  we  imme- 
diately accuse  the  evil  influence  of  the  womb,  which  is  most  fre- 
quently innocent,  ( pleurumque  insons  est,)  and  gravely  assert  that 
there  must  be  something  hysterical  in  it,  ( aliquid  hystericum  snbesse 
pronunciamus  ;)  then  we  prescribe  some  form  of  treatment  depend- 
ent on  the  evasive  and  convenient  explanation  which  veils  our  igno- 
rance, ( qui  saepe  tantum  ignorantiae  subterfiigium  est.) 

We  have  still  to  treat  of  uterine  neuralgia,  to  which  M.  Louj^er- 
Villermay  has  given  the  name  of  hysteralgia. 


OF  HYSTERALGIA. 

By  this  term,  derived  from  the  vampa,  uterus , and  axyo s,  pain , is 
usually  meant  any  pain  in  the  gestative  organ,  independent  of  in- 
flammation of  that  viscus.  This  affection,  which  is  for  the  uterus 
what  gastralgia  is  for  the  stomach,  scarcely  ever  appears  except 
during  the  period  of  the  sexual  existence,  say  from  fifteen  to  forty- 
five  years  of  age.  It  has  been  observed,  that  many  girls,  before 
reaching  the  age  of  puberty,  and  even  some  married  women,  are 
subject  to  it  at  each  return  of  the  menses.  In  some  cases,  hysteralgic 
pains  are  brought  on  by  the  first  conjugal  approaches,  and  they  fre- 
quently succeed  to  the  sensation  of  voluptuous  spasm  which  occurs 
during  sexual  union.  Without  being  the  effect  of  leucorrhcea,  of 
displacement,  or  of  rheumatism  of  the  uterus,  etc.,  hysteralgia  is  a 

* L’Histoire  de  l’Academie  des  Sciences,  (year  1752,  p.73,)  mentions  several  cases 
of  hysteria  and  other  spasmodic  disorders  cured  by  the  employment  of  rapid,  abrupt 
and  unexpected  music.  Pomme  and  Tissot  relate  several  examples  of  it.  Goubelly, 
who  is  the  author  of  a learned  dissertation,  ( An  hystericis  insu/tibus  prxcavendis 
musice,  Paris,  1771,  collection  de  theses  erolico-medicales,)  has  derived  great  advan- 
tage from  the  employment  of  music  in  the  treatment  of  hysteria  and  all  the  vapoury 
affections  of  women.  We  shall  dwell  at  some  length  on  this  subject,  in  a work 
which  we  purpose  publishing,  and  which  is  to  have  for  title,  Del' histoire philosophiqut 
de  la  musique  et  de  I'injluence  de  cel  art  sur  les  passions  et  sur  la  santc  de  I'/iomme. 


HYSTERALGIA. 


541 


symptom  which  often  accompanies  those  different  disorders,  but; 
which,  instead  of  being  like  them,  continuous,  has  longer  or  shorter 
periods  of  perfect  calm.  Hysteralgia,  also,  sometimes  coincides  with 
paroxysms  of  intermittent  fever;  during  the  apyrexia,  there  often 
remains  slight  sensibility  merely  of  the  hypogastrium,  which  might 
lead  us  to  suspect  the  presence  of  a slight  metritis,  a condition,  more- 
over, which  has  been  known  to  arise  when  the  nervous  affection  of 
the  uterus  has  lasted  a great  length  of  time. 

The  symptoms  of  uterine  neuralgia  are  more  or  less  violent  pain, 
with  sensations  of  pricking  and  twisting,  and  often  a burning  heat 
even,  seated  in  the  centre  of  the  pelvic  excavation,  and  irradiating, 
in  some  cases,  to  the  rectum,  anus,  groins,  and  loins,  and  especially 
to  the  vagina  and  vulva.  Exploration  by  the  Touch  and  speculum, 
shows  that  the  genital  organs  present  neither  redness,  swelling,  nor 
abnormal  sensibility.  The  pain,  however,  may  reach  such  a degree 
of  severity,  that  the  patient  is  thrown  into  a state  of  agitation  and 
despair,  capable  of  giving  rise  to  a suspicion  of  her  being  attacked 
with  mental  alienation. 

The  treatment  of  hysteralgia  consists  in  the  use  of  baths ; of 
emollient  and  narcotic  enemata  and  injections ; and  of  cataplasms, 
and  liniments  of  the  same  nature  applied  to  the  hypogastric  region ; 
finally,  repose,  continence,  demulcent  drinks,  caustic  issues  on  the 
thighs  or  arms,  and  especially  frictions  of  the  hypogaster  with  tartar- 
emetic  ointment,  are  additional  means  that  ought  not  to  be  neglected. 
Should  the  disease  assume  a periodical  form,  either  with  or  without 
fever,  recourse  must  be  had  to  the  preparations  of  cinchona,  and  espe- 
cially to  the  sulphate  of  quinia,  in  combination  with  opium.  If  the 
hysteralgia  were  a symptom  of  some  other  affection  of  the  uterus, 
we  should  seek,  above  all,  to  overcome  the  primary  disease. 

With  this,  we  conclude  our  remarks  upon  the  diseases  peculiar  to 
females  ; we  have  passed  by,  without  notice,  those  that  are  relative 
to  reproduction,  and  that  are  classed  in  the  Sixth  Section  of  our 
synoptic  table,  because,  on  the  one  hand,  they  do  not  enter  into  the 
plan  of  the  work,  and  on  the  other,  because  they  are  sufficiently 
numerous  and  important  to  induce  us  to  devote  to  their  consideration 
a particular  treatise,  which  will  be  independent  of  this,  and  which  we 
purpose  publishing  after  some  time. 

Though  it  is  evident  from  the  sad  picture  we  have  just  traced  in 
lengthened  detail,  that  the  diseases  peculiar  to  women  are  for  the 
most  part  extremely  serious,  it  is  also  evident,  that  we  may  generally 
hope  for  their  prevention  and  cure,  by  opposing  them  in  good  time, 
by  the  various  prophylactic  and  therapeutical  agents,  which  have 
been  tested  by  experience,  and  which  justify,  day  by  day,  the  old 
adage : 

Principiis  obsta;  sero  medecina  paratur 
Cum  mala  per  longas  invaluere  moras. 

Ovid.  Remedia  amoris,  ver.  91,  92. 


542 


HYGIENIC  RULES — PUBERTY  AND  MENSTRUATION. 


CHAPTER  X. 

SPECIAL  HYGIENE  OF  WOMEN. 


Pluris  est  labantem  sustinere,  quam  lapsum  erigere. — Sejteca. 


After  treating  of  the  diseases  peculiar  to  women,  we  naturally 
come  to  speak  of  the  means  of  avoiding  them  as  far  as  possible,  and 
of  the  precautions  to  be  taken,  in  order  to  render  less  difficult  and 
laborious  the  important  functions  assigned  them  by  nature.  The 
object  we  propose  to  ourselves,  in  this  chapter,  is,  therefore,  to  guide 
them  through  the  midst  of  the  dangers  which  threaten  them  during 
those  stormy  periods,  and  physiological  transitions  that  mark  the  chief 
phases  of  their  life.  Though  the  counsels  we  give  them  are  far  from 
having  the  power  of  always  preventing  their  diseases,  we  have,  at 
least,  the  certainty  that  they  will  constantly  weaken  the  morbific 
influences  which  produce  them. 

To  proceed  with  greater  method  in  the  application  to  women  of  the 
hygienic  precepts  which  belong  to  their  sex,  we  have  thought  best 
to  follow  the  physiological  order  in  which  the  principal  periods  of 
their  existence  succeed  each  other,  and  not  to  restrict  ourselves  to 
the  six  divisions  adopted  by  modern  authors,  except  when  we  shall 
be  occupied  with  what  concerns  them  chiefly  in  general  hygiene. 

HYGIENIC  RULES  CONCERNING  PUBERTY  AND  MENSTRUATION. 

When  a young  girl  shows,  by  the  unfolding  of  her  physical  facul- 
ties, that  she  is  approaching  the  completion  of  her  full  development, 
she  needs  the  closest  watching,  and  a management  having  a different 
object  from  that  towards  which  her  childish  constitution  tended. 
Whereas  before  puberty  she  existed  but  for  herself  alone,  having 
reached  this  age,  the  spring-time  of  life,  when  all  her  charms  are  in 
bloom,  she  now  belongs  to  the  entire  species  which  she  is  destined 
to  perpetuate,  by  bearing  almost  all  the  burthen  of  reproduction. 

During  infancy,  the  vital  forces  tend  to  act  equally  upon  all  her 
organs,  but  at  the  epoch  of  puberty,  the  chief  efforts  of  the  organ- 
ism are  in  some  sort  concentrated  upon  the  sexual  parts,  whose  func- 
tions are  executed  only  during  the  second  period  of  life. 

As  at  this  period,  the  instinct  of  modesty  often  leads  young  girls  to 
conceal  their  first  menstrual  haemorrhage,  it  becomes  the  duty  of 
mothers  to  inform  them  of  the  revolution  they  are  about  to  undergo, 
and  to  announce  to  them  that  the  sanguine  discharge,  which  they  are 
to  become  subject  to,  is  a natural  function  upon  which  their  health 
will  henceforwards  depend.  Young  persons,  kept  in  entire  ignorance 
upon  this  point,  and  taking  their  new  condition  for  some  shameful  in- 
firmity, have  been  known  to  oppose  the  salutary  efforts  of  nature,  by 


HYGIENIC  RULES — PUBERTY,  MENSTRUATION.  543 

means  of  lotions,  injections,  and  other  equally  dangerous  agents. 
The  exact  truth,  therefore,  should  be  told  to  girls  just  arrived  at  pu- 
berty, because,  though  it  is  dangerous  to  know  too  much,  it  is  more 
dangerous  to  be  entirely  ignorant. 

The  general  attention  required  by  women  at  entering  the  brilliant 
and  stormy  crisis,  which  is  terminated  by  the  appearance  of  the 
menses,  consist  in  fulfilling  two  principal  indications : l,to  moderate 
the  excitement  and  disorder  resulting  from  the  momentary  plenitude 
of  the  circulatory  system  ; 2,  so  to  direct  the  efforts  of  nature,  that 
they  may  exert  their  chief  action  upon  the  sexual  organs,  in  which 
the  vital  forces  ought,  so  to  speak,  to  centre  and  terminate. 

A carefully  regulated  regimen  is  of  all  means  the  most  appropriate 
one  for  fulfilling  the  first  indication ; the  food  of  a young  girl  at 
puberty  ought  to  consist  principally  of  vegetable  substances,  of  pre- 
parations of  milk,  of  the  tender  meats,  and  of  light  and  easily  diges- 
tible substances.  Water,  with  very  small  quantities  of  wine,  cooling 
drinks,  and  light  beer,  should  form  the  chief  part  of  her  drink  ; solid 
and  highly  seasoned  meats,  sour  and  unripe  fruits,  stimulating  arti- 
cles, alcoholic  liquors,  and  coffee,  as  well  as  the  daily  use  of  tea,  must 
be  carefully  avoided ; warm  baths,  taken  from  time  to  time,  will  con- 
tribute, together  with  the  regimen,  to  produce  a general  detergent 
effect,  and  will  have  the  advantage,  moreover,  of  softening  the  skin 
and  dispersing  the  cutaneous  eruptions  to  which  girls  are  particularly 
subject  at  the  period  of  puberty.  Sanguine  evacuations,  particularly 
general  bleedings,  are  almost  always  contra-indicated  at  this  time, 
and  their  employment  becomes  justifiable  only  in  case  there  should 
exist  some  acute  and  dangerous  inflammation  of  an  important  organ. 
Issues  and  derivatives,  likewise,  should  never  be  employed,  except 
with  great  care,  and  in  cases  when  the  indications  for  their  use  are 
very  positive. 

To  fulfil  the  second  indication,  to  wit,  to  place  the  genital  organs, 
especially  the  uterus,  in  a condition  favourable  to  their  becoming  the 
seat  of  the  irritation  which  precedes  the  menstrual  exhalation,  we 
should  advise  gymnastic  exercises,  walking  and  riding,  running ; 
the  games  of  battledore,  the  jumping  rope,  the  hoop,  and  riding 
on  horseback ; lastly,  frictions  about  the  pelvis  and  inferior  extremi- 
ties, the  use  of  flannel-drawers,  etc.,  are  additional  means  very 
useful  for  inviting  the  flow  of  the  menses.  If  the  important  function 
delays  its  appearance  too  long,  and  particularly  if  the  girl  suffers 
any  of  the  evil  effects  of  amenorrhoea,  we  should  resort  to  very  warm 
hip-baths  and  pediluvia ; to  aromatic  fumigations ; to  applications 
of  cups  to  the  thighs,  and  leeches  to  the  vulva ; and  finally,  to  the 
various  means  pointed  out  under  the  head  of  essential  amenorrhoea. 
At  this  period,  in  particular,  we  must,  forbid  the  wearing  of  corsets 
with  busks  and  whalebones,  and  tight  clothing,  which  obstruct  the 
free  development  of  the  pelvis,  of  the  thorax,  and  of  the  neck,  and 
which  might  prove  the  origin  of  most  of  the  diseases  whose  sad 
picture  we  have  just  sketched. 

It  will  be  well,  at  the  same  time,  to  pay  attention  to  the  moral 
condition  of  the  patient,  and  for  this  reason,  it  is  of  the  highest  im- 


544  HYGIENIC  RULES  — PUBERTY,  MENSTRUATION. 

portance  to  remove  young  girls  from  boarding-school,  when  they 
approach  the  age  of  puberty,  in  order  to  exercise  a constant  watch 
over  them.  We  should  prevent,  as  far  as  possible,  the  false  emotions 
produced  by  the  reading  of  licentious  books,  especially  of  the  highly- 
wrought  romances  of  the  modern  school,  which  are  the  more  inju- 
rious, as  all  the  faculties  become,  as  it  were,  overpowered  by  the 
desire  to  experience  the  sentiment  which  these  works  always  repre- 
sent in  an  imaginary  and  exaggerated  strain.  Frequent  visits  to  the 
theatre  ought  to  be  carefully  avoided,  because  they,  also,  may  give 
rise  to  sensations  conformable  to  the  moral  condition,  which  is  natu- 
rally, at  puberty,  already  too  much  exalted.  These  powerful  exciting 
agents,  and  still  more  frequently,  the  violent  intimacies  formed  at 
boarding-school,  tear  the  veil  of  modesty,  and  destroy,  for  ever,  the 
seductive  innocence  which  is  the  most  charming  ornament  of  a 
young  girl.  Endowed  with  an  organization  eminently  impressiona- 
ble, she  soon  contracts  improper  habits,  and  constantly  tormented  by 
an  amorous  melancholy,  becomes  sad,  dreamy,  sentimental  and  lan- 
guishing. Like  a delicate  plant,  withered  by  the  rays  of  a burning 
sun,  she  fades  and  dies  under  the  influence  of  a poisoned  breath.  The 
desires  for  happiness  and  love,  so  sweet  and  attractive  in  their  native 
truth,  are  in  her  converted  into  a devouring  flame,  and  onanism,  that 
execrable  and  fatal’evil,  soon  destroys  her  beauty,  impairs  her  health, 
and  conducts  her  almost  always  to  a premature  grave  ! 

Comme  une  flear  dessechee 
Tombe,  la  tete  penchee, 

Feuille  a feuille,  sur  le  sol: 

Ainsi  meurt  la  pauvre  fille. 

En  elle  plus  rien  ne  brille, 

Que  les  perles  de  son  col. 

(L.  A.  Bekthaxd.) 

It  often  happens  that,  in  spite  of  all  the  care  and  precaution  of  a 
tender  and  prudent  mother,  the  imagination  of  a girl  becomes  exalted 
to  such  a point,  as  to  silence  the  voice  of  reason  and  shame.  In  this 
unequal  contest,  where  nature  often  gains  the  victory  over  social 
institutions,  we  should  resort  to  the  use  of  means  which  may,  by  a 
powerful  diversion,  counterbalance  and  destroy  the  erotic  exaltation. 
Experience  has  proved,  that  among  these  means,  severe  occupation 
of  the  mind,  and  bodily  exercises  carried  so  far  as  to  induce  fatigue, 
are  more  efficacious  than  all  the  drugs  of  the  apothecary  ; the  Fable 
which  represents  the  chaste  Diana  as  the  goddess  of  the  chase,  is 
an  ingenious  allegory,  which  seems  to  prove  that  the  ancients  had 
discovered,  in  corporeal  exercises,  the  power  of  blunting,  and  even  of 
extinguishing  the  stings  of  love.  A strict  superintendence  ; a milk 
and  vegetable  diet ; the  study  of  history,  geography,  and  belles-let- 
ters  ; counsels  founded  upon  religion  and  morality  ; the  frequent  use 
of  bathing  ; the  precaution  never  to  leave  young  persons  alone,  and 
especially  to  make  them  retire  late  and  rise  early  ; such  are  the  means 
to  which  we  may  almost  always  resort  with  success. 

A directly  opposite  plan  should  be  adopted  for  girls  who,  though 
arrived  at  the  nubile  age,  are  cold,  apathetic,  and  indifferent ; and,  it 


HYGIENIC  RULES  FOR  WOMEN. 


545 


is  to  such  only  that  the  culture  of  the  fine  arts,  the  frequenting  of 
balls,  of  theatres,  of  crowded  assemblies,  and  even  the  reading  of 
certain  'imaginative  works  and  romances,  will  not  be  hurtful,  and 
might  even  prove  useful  in  exciting  their  sensibility,  and  thus  inviting 
the  menstrual  exhalation. 

From  the  epoch  of  puberty%to  the  critical  age,  the  menstrual  dis- 
charge requires  certain  cares  and  precautions,  which  it  is  important 
to  understand.  While  the  haemorrhage  is  present,  women  ought  to 
refrain  from  taking  baths,  and  from  washing  the  hands  and  genital 
organs  with  cold  water;  they  should  also  avoid  cold  feet;  they  should 
not  remain  with  the  arms  or  neck  uncovered,  and  must  abstain  from 
iced,  exciting  and  alcoholic  drinks,  such  as  sherbets,  coffee,  tea, 
liqueurs,  etc.;  coitus,  also,  ought  to  be  proscribed,  because  the  excite- 
ment determined  by  it  in  the  genital  organs,  may  occasion  either 
metrorrhagia,  or  more  or  less  complete  suppression,  and  secondarily 
a utero-vaginal  inflammation.  It  is  well,  also,  to  avoid  sitting  upon 
cold  and  damp  places,  for  example  the  earth,  a stone  bench,  a grassy 
bank,  etc.  The  napkins,  or  chaitffoirs , employed  to  receive  the 
fluid  of  the  menses,  as  it  escapes  from  the  genital  parts,  ought 
always  to  be  well  aired,  and  in  winter  warmed  before  being  applied. 
If  the  discharge  is  too  abundant,  it  may  be  remedied  by  a vegetable 
and  milk  diet;  by  repose;  by  the  horizontal  position;  by  cooling 
and -sedative  drinks,  as  barley  water,  whey,  weak  lemonade,  etc.;  if 
the  female  is  of  lymphatic  temperament,  she  must  use,  on  the  con- 
trary, a tonic  diet,  composed  chiefly  of  roast  meats,  feculent  sub- 
stances, and  rich  soups.  When  menstruation  is  entirely  or  partially 
suppressed,  in  consequence  of  some  imprudence  or  unexpected  occur- 
rence, it  is  necessary  to  endeavour  to  recall  it,  by  means  of  a warm 
infusion  of  balm  and  orange  flowers.  Rest  in  bed,  warmth  to  the 
thighs  and  legs,  maintained  by  bottles  filled  with  warm  water,  are 
other  means  which  should  not  be  neglected. 

We  ought  to  remark,  moreover,  that  during  the  flow  of  the  menses, 
except  some  absolute  necessity  arises,  it  is  proper  to  abstain  from  the 
use  of  bleeding,  of  purgatives,  of  emetics,  and  all  the  therapeutical 
means  which  act  energetically,  and  which  might  occasion  an  impres- 
sion capable  of  disturbing  the  salutary  efforts  of  nature.  In  general, 
women  may  escape  most  of  the  disorders  of  menstruation,  either  by 
exercising,  to  a greater  extent,  the  muscular  system,  which  they 
too  often  condemn  to  dangerous  inaction ; by  abstaining  from  excit- 
ing!:, salted,  or  highly-seasoned  food  and  from  stimulating  drinks ; or 
lastly,  by  taking  care  to  clothe  themselves  suitably  during  the  winter; 
and  especially  by  wearing  flannel  drawers,  some  days  before,  and 
during  the  epoch  of  the  menses  principally.  It  is,  likewise,  very  im- 
portant that  they  should  abstain,  during  the  presence  of  the  discharge, 
from  all  intellectual  labour,  and  from  severe  study,  which,  by  esta- 
blishing a high  cerebral  excitement,  determine  an  unequal  distribution 
of  the  vital  forces,  and  cause  an  afflux  towards  the  brain  of  the  blood 
which  ought  to  flow  towards  the  genital  apparatus.  Before  conclud- 
ing what  we  had  to  say  upon  the  attention  to  hygiene  that  men- 
struation requires,  we  will  add,  that  so  long  as  the  function  lasts, 
35 


546 


HYGIENIC  RULES  FOR  MARRIAGE. 


women  ought  to  be  the  object  of  the  most  attentive  kindness,  and  of 
a solicitude  capable  of  preserving  them,  as  far  as  possible,  from  the 
unhappy  influences  of  the  physical  and  moral  causes  which  affect 
them  then  more  strongly  than  at  any  other  period.  It  is  well  to  say, 
also,  that  if  some  amongst  them  become  subject  at  these  periods  to 
caprices,  to  sadness,  and  unequal  te paper,  we  should  always  bear 
these  transient  humours  with  indulgence,  because  they  depend  upon 
the  action  of  the  body  upon  the  mind,  and  upon  an  active  irritation, 
which  is  radiated  from  the  uterus  towards  the  other  organs,  and  espe- 
cially towards  the  brain. 

HYGIENIC  RULES  IN  RELATION  TO  THE  UNION  OF  THE  SEXES. 

If,  on  the  one  hand,  as  M.  Virey*  says,  the  condition  of  virginity, 
in  our  civil  institutions,  is  a state  of  violence  against  the  impulsions 
of  nature,  v§ry  different  from  the  free  state  of  the  young  females  of 
animals  who  are  subjected,  at  the  period  of  their  loves,  to  the  yoke 
of  passion ; if,  on  the  other  hand,  it  is  generally  admitted  that  mar- 
riage is  the  state  most  favourable  to  the  happiness,  well-being,  and 
health  of  man,  it  is  important  to  respond  to  the  call  of  nature,  as 
soon  as  the  complete  development  and  perfect  conformation  of  all 
the  organs  allow.  In  the  infancy  of  the  world,  the  sexes  obeyed  in 
their  union  only  the  natural  sentiment  which  attracted  them  to- 
wards each  other;  but  philosophers,  physicians  and  legislators,  made 
of  marriage  one  of  the  chief  objects  of  their  meditations.  Seeking 
to  determine  the  more  01;  less  advantageous  influence  which  might 
result  from  it  to  the  people,  whose  happiness  they  sought  to  assure, 
all  agreed  that  the  most  serious  inconveniences  might  flow  from  the 
premature  union  of  the  two  sexes.  In  order  to  prevent  the  evil  effects 
of  marriage  before  the  full  development  of  the  constitution,  legislators 
have  determined  its  epoch.  Lycurgus  and  Plato  fixed  it  at  seven- 
teen years  for  girls,  and  Aristotle  at  eighteen.  Among  the  Romans, 
women  were  authorized  by  the  Poppcean  law,  to  marry  at  the  age  of 
twelve  years;  lastly,  the  Athenians,  less  scrupulous,  permitted  mar- 
riage as  soon  as  individuals  believed  themselves  fit  to  fulfil  its  end. 
This  law,  fatal  to  population  in  general,  and  especially  dangerous  for 
women,  accorded  with  the  customs  and  warlike  policy  of  the  people 
of  Athens.  As  it  would  be  both  useless  and  fastidious  to  cite  all  the 
laws  and  opinions  relative  to  marriage,  we  shall  confine  ourselves  to 
saying,  that  the  period  ought  to  vary  tvith  the  difference  of  place,  of 
climate,  of  people,  and  with  the  degree  of  civilization,  since  these 
several  circumstances  may  hasten  or  retard  the  first  appearance  of 
the  menses  and  the  age  of  complete  nubility. 

The  French  laws,  before  the  Revolution,  forbade  legal  union,  for 
girls,  before  the  age  of  twelve  years ; but,  by  the  present  code,  they 
cannot  enter  into  the  conjugal  tie  until  they  have  reached  the  age  of 
fifteen  years  complete.  The  French  legislators  have  permitted  mar- 
riage at  this  early  period  after  birth,  because  they  deemed  it  neces- 

* De  la  femme,  sous  les  rapports  physiologique,  moral  et  litteraire,  ch.  xi.p.  78. 


HYGIENIC  RULES  FOR  MARRIAGE. 


547 


sary  for  the  interest  of  good  manners,  inasmuch  as  accidental  con- 
nections between  the  sexes  might  occur  at  that  period,  to  leave 
some  means  by  which  to  repair  a fault,  and  legitimatize  children 
who,  but  for  this  provision,  would  have  a false  and  unhappy  posi- 
tion in  society.  Moreover,  if  it  be  recollected  that  marriage  is  the 
most  effectual  means  of  removing  the  evils  resulting  from  the  violent 
desires  which  are  often  excited  in  young  girls,  at  an  early  period,  by 
the  education  they  receive  and  by  the  prevailing  customs  of  society, 
it  will  be  agreed,  undoubtedly,  that  the  civil  code  has  been  digested 
with  the  utmost  wisdom.  Nevertheless,  regarding  woman  only  in 
her  physiological  aspect,  we  think  that  from  eighteen  to  twenty-five 
is  the  age  at  which  women  may  marry  most  advantageously  for 
themselves  and  for  their  children.  Besides,  there  is  a rule  by  which 
we  may  always  guide  ourselves,  which  is,  to  place  at  least  two  years 
between  the  time  of  marriage  and  the  first  appearance  of  the  menses. 
It  is  rare  for  the  constitution  to  have  acquired,  before  this  period,  the 
development  necessary  for  the  reproduction  of  the  species.  “ If,”  as 
remarks  M.  Lachaise,  in  his  Hygiene , “ the  indispensable  processes 
of  nature,  occupied  with  the  completion  of  its  organization,  are 
broken  in  upon  by  the  premature  enjoyments  of  marriage,  the 
female  will  be  exposed  to  a thousand  risks,  in  her  new  position. 
Become  pregnant,  she  will  be  unable  to  support,  without  the  great- 
est difficulty,  and  at  the  expense  of  her  health,  the  innumerable  and 
unavoidable  inconveniences  of  that  condition : she  will  be  liable  to 
abortions  and  haemorrhages,  and  the  pangs  of  childbirth  may  cost 
her,  perhaps,  her  life.  Become  the  mother  of  delicate  and  sickly 
infants,  she  will  pass  her  youth  in  uneasiness  and  tears;  give  to  the 
offspring  of  her  love  an  impoverished  milk ; yield  herself,  in  order 
to  rear  them,  to  cares  and  watchings  beyond  her  strength ; hasten 
for  them  the  approach  of  old  age,  and  tear  herself,  perhaps,  from  life 
at  a period  when  she  is  ordinarily  strongest  and  most  active.” 
Though  premature  marriages  are  not  invariably  followed  by  such 
fatal  consequences,  we  may  say  that  they  always  influence,  more  or 
less,  the  physical  and  moral  condition,  and  hasten  the  termination, 
already  too  precipitate,  of  youth  and  beauty. 

In  women  who  are  well  formed  and  fully  developed,  the  first 
enjoyments  generally  produce  a favourable  impression  upon  the 
constitution : nevertheless,  it  sometimes  happens  that  the  generative 
organs  become  the  seat  of  inflammation,  or  that  newly-married  per- 
sons suffer  from  some  spasmodic  disorders  which  readily  yield  to 
absolute  repose  of  the  organs,  to  the  employment  of  general  baths, 
sedative  drinks,  and  narcotic  and  emollient  enemata  and  lotions: 
lastly,  to  general  depletion,  where  the  pulse  is  full  and  the  reaction 
very  violent. 

While  a moderate  indulgence  in  the  venereal  act  generally  pro- 
duces useful  effects,  when  too  often  repeated,  it  occasions  lassitude, 
feebleness,  and  general  depression ; the  beauty  is  soon  destroyed,  the 
grace  and  freshness  of  youth  are  withered ; finally,  when  the  abuse 
of  coitus  is  kept  up,  it  may  determine  inflammations  and  ulcerations 
of  the  vagina  and  uterus,  leucorrhoea,  uterine  haemorrhages,  disorders 


548 


HYGIENIC  RULES  FOR  MARRIAGE. 


of  the  digestive  and  nervous  apparatus,  acute  and  chronic  gastritis, 
attacks  of  hysteria  and  nymphomania,  feebleness  of  all  the  senses, 
loss  of  memory,  stupidity,  moral  inferiority,  caries  of  the  vertebrae, 
aneurisms,  especially  of  the  heart,  phthisis  pulmonalis,  marasmus 
and  death. 

Under  all  circumstances,  young  married  persons  ought  to  proportion 
their  pleasure  to  their  forces,  and  should  recollect  that  the  first  conjugal 
approaches  require  certain  cares  and  precautions,  the  forgetfulness  of 
which  might  lead  to  the  most  unhappy  results.  When  the  consum- 
mation of  the  marriage  meets  with  too  great  resistance,  especially 
when  there  is  disproportion  between  the  organs,  the  husband,  young, 
full  of  vigour  and  sometimes  inexperienced,  instead  of  abandoning 
himself  to  all  his  transports,  should  seek  to  overcome  the  obstacles 
with  care  and  circumspection.  In  general,  the  difficulties  which  the 
first  essays  of  marriage  present,  are  least  during  the  period  of  the 
menses  and  for  some  days  afterwards.  We  may  remark,  also,  that  the 
use  of  unctuous  substances,  of  emollient  fomentations,  and  of  general 
baths,  and  that  the  effusion  of  blood,  even,  which  generally  follows 
the  first  attempts,  may  determine  a useful  relaxation  in  cases  of  dif- 
ficulty. Nevertheless,  if  too  great  a resistance  should  be  met  with, 
far  from  making  violent  efforts  that  might  endanger  the  life  of  the 
woman,  some  unnatural  conformation  ought  to  be  suspected,  and  the 
assistance  of  the  surgeon  be  invoked  against  an  obstacle  which  he 
alone  can  surmount  without  risk. 

As  conception  is  the  most  natural  consequence  of  the  genital  act, 
and  though  the  reproduction  of  the  species  is  the  chief  end  of  the 
institution  of  marriage,  there  are  yet  certain  circumstances,  which, 
however  imperious  the  tone  of  the  senses,  and  however  powerful  the 
laws  of  the  social  condition,  should  be  held  as  authoritative  enough 
to  forbid  the  sexual  approach,  as  regards  some  women,  in  whom  it 
threatens  to  become  the  fruitful  source  of  dangerous  diseases,  and 
often,  indeed,  the  cause  of  death  itself.  Among  the  number  of  de- 
formities which  contra-indicate  marriage  for  such  persons,  we  should 
place  in  the  first  class  those  which  are  capable  of  preventing  the  act 
of  generation,  or  that  of  parturition,  such  as  absence  of  the  vagina  or 
insufficient  capacity  of  the  pelvis.  The  latter-named  fault  of  con- 
formation would  place  the  woman  under  the  cruel  alternative  of 
undergoing  the  Caesarian  operation,  or  that  for  the  section  of  the 
symphysis;  or,  at  least,  of  seeing  her  offspring  sacrificed  and  ex- 
tracted piecemeal. 

In  general,  we  may  presume  that  there  is  vicious  conformation  of 
the  pelvic  cavity,  whenever  we  find  a curve  in  the  vertebral  column, 
which  allows  the  last  lumbar  vertebra  to  sink  in  towards  the  poste- 
rior and  upper  part  of  the  pelvis,  where  the  haunch  bones  are  not 
very  apparent,  and  are  very  much  elevated  on  one  side  ; where  the 
thighs  are  closely  approximated  towards  each  other,  and,  in  fine, 
where  a curve  in  the  long  bones  and  swelling  of  their  articular 
extremities  indicate  a general  rachitic  condition.  It  is  true,  how- 
ever, that  we  have  seen  some  horribly  deformed  women,  with  a 
well-formed  pelvis,  and  lying-in  very  easily,  while  there  are  others 


HYGIENIC  RULES  FOR  MARRIAGE. 


549 


who,  with  all  the  appearance  of  a regular  conformation,  cannot 
bring  their  children  into  the  world,  and  almost  inevitably  perish, 
because  they  have  the  superior  strait  of  the  pelvis  with  an  antero- 
posterior diameter  of  not  more  than  two  inches.  Parents  who  should 
suspect  the  existence  of  such  pelvic  deformity  in  their  children,  ought 
never  to  consent  to  their  marriage,  without  first  taking  the  opinion 
of  a capable  physician ; for  though  an  examination  into  the  facts  of 
such  a case  gives  a shock  to  the  modesty  of  the  female,  such  a senti- 
ment ought  not  to  be  put  in  balance  against  the  life  both  of  a mother 
and  her  child. 

Among  the  disorders  that  ought  to  be  admitted  as  obstacles  to  a 
legal  union,  we  place  pulmonary  consumption,  aneurism  of  the  heart 
and  of  the  large  arterial  trunks,  idiocy,  insanity,  and  even  epilepsy, 
where  that  disease  continues  after  the  age  of  puberty. 

In  following  out  the  order  in  which  the  various  physiological 
phases  of  the  life  of  the  female  succeed  each  other,  we  ought  not  to 
speak  of  the  hygienic  precautions  applicable  to  the  functions  and 
various  states  of  the  female,  having  relation  to  the  reproductive 
faculty ; we  pass  them  by  in  silence,  because  we  intend,  as  we  have 
stated  both  in  the  preface  and  in  the  last  chapter,  to  speak  of  them 
very  fully  in  another  and  independent  treatise,  which  we  propose  to 
publish,  upon  the  diseases  and  accidents  connected  with  conception, 
pregnancy,  parturition  and  lactation,  but  which  do  not  constitute  a 
part  of  the  plan  of  this  work. 

On  account  of  the  reasons  now  set  forth,  we  shall  at  once  pro- 
ceed to  contemplate  the  prophylactic,  hygienic  and  therapeutical 
measures  applicable  for  the  prevention  of  those  disorders  to  which 
women  are  obnoxious  at  the  change  of  life,  under  the  influence  of 
a final  cessation  of  the  catamenial  office. 

HYGIENIC  RULES  RELATIVE  TO  THE  CHANGE  OF  LIFE. 

The  period  of  the  final  cessation  of  the  menses  exhibits  a less  flat- 
tering and  often  a no  less  stormy  prospect  than  that  of  their  first 
appearance.  Compelled  to  yield  to  the  power  of  time,  women  now 
cease  to  exist  as  for  the  species,  and  henceforward  live  only  for 
themselves.  Their  features  are  stamped  with  the  impress  of  age, 
and  their  genital  organs  are  sealed  with  the  signet  of  sterility.  This 
great  revolution,  this  remarkable  epoch  of  life,  which  most  commonly 
happens  between  the  age  of  forty  and  fifty  years,  but  which  is  sub- 
ordinate to  the  influences  of  climate,  constitution  and  mode  of  life, 
to  the  social  position  and  the  healthful  or  morbid  condition  of  the 
patient,  requires  such  cares  and  precautions,  of  a hygienic  nature,  as 
may  serve,  as  far  as  possible,  to  prevent  the  evils  to  which  women 
are  then  known  to  be  liable. 

The  first  advice  they  ought  to  receive,  is  an  advice  to  reject  all 
sorts  of  drugs  and  preparations  to  which  are  attached  such  titles  as 
health-pills,  elixir  of  long  life,  or  elixir  of  propriety,  and  all  the 
receipts  that  are  loudly  proclaimed  by  ignorance,  puffed  by  charla- 
tanism and  old-womanism,  accredited  by  the  attractions  of  a vogue  and 


550 


HYGIENE  — OF  CHANGE  OF  LIFE. 


by  millions  of  so-called  miraculous  cures : the  approach  to  the  critical 
period  less,  perhaps,  than  any  other  epoch,  admits  of  any  infractions 
as  to  regimen,  dress,  bodily  exercise,  sleep  and  watching,  the  various 
excretions  and  also  the  affections  and  passions  of  the  soul.  The  diet, 
which  ought  not  to  be  too  nutritious,  may  be  composed  of  white 
meats,  veal,  chicken,  fresh-water  fish,  vegetables,  such  as  succory, 
spinach,  acidulous  fruits,  cooked,  and  rdw  fruits  very  ripe.  Such  a 
person  should  reject  all  sorts  of  spiced  dishes,  ragouts,  black  and 
salted  meats,  coffee,  tea,  spirituous  liquors,  and,  in  fine,  all  stimulating 
and  indigestible  food.  Plethoric  women,  who  are  subject  to  copious 
menstrual  discharges,  should  renounce  late  suppers,  should  drink 
whey,  cooling  beverages,  infusions  with  succory,  and  acidulous  mine- 
ral waters.  All  such  women  ought  to  make  it  a rule  to  take  moderate 
exercise,  with  a view  to  distribute,  throughout  the  entire  system,  the 
excitability  which  is  thus  withdrawn  from  the  reproductive  system. 
Exercise,  taken  in  attending  to  household  affairs,  is  so  much  the  more 
favourable,  as  it  is  proportioned  to  the  physical  strength,  and  super- 
adds, to  the  natural  effects  of  toil,  the  internal  satisfaction  arising  from 
the  fulfilment  of  duty.  Lastly,  riding  out  in  the  country,  where  one 
may  go  to  inhale  the  bracing  air  of  the  morning;  the  cares  demanded 
for  the  proper  culture  of  flowers;  short  excursions  into  pleasant 
regions  of  country,  where  the  land  is  high  and  dry,  especially  in 
agreeable  company,  also  constitute  the  kinds  of  exercise  from  which 
may  be  derived  the  happiest  results. 

Women  who  have  reached  their  critical  period  of  life,  should,  with 
more  than  usual  care,  withdraw  themselves  from  the  influences  of 
atmospherical  vicissitudes,  and  especially  from  that  of  a cold,  damp 
atmosphere,*  which  often  gives  rise  to  catarrhal  disorders,  leucor- 
rhoeas,  &c.  They  would  also  do  well  to  avoid,  especially  at  those 
periods  at  which  they  were  accustomed  to  menstruate — they  would 
do  well,  we  say,  to  avoid  large  assemblies,  theatres,  heated,  close 
rooms,  where  only  impure  air  can  be  breathed : they  ought  also  to 
eschew  all  low  and  damp  situations,  to  give  up  the  use  of  foot- 
warmers;  they  ought  not  to  sleep  upon  feather  beds,  nor  in  any  bed 
that  is  too  soft  and  too  warm,  for  such  are  attended  with  the  disadvan- 
tage of  promoting  plethoric  accumulations,  and  disposing  the  system 
to  attacks  of  uterine  haemorrhage,  of  causing  constipation  of  the 
bowels,  and  exciting  the  generative  organs,  which  should  henceforth 
be  left,  as  far  as  possible,  in  a state  of  inaction.  Sleep,  if  prolonged 
beyond  six  or  seven  hours,  long  watchings,  too  much  exercise  of  the 
mental  faculties ; sensations,  whether  too  acute  or  too  profound ; 
wrath,  love  of  play,  and  all  sorts  of  passionate  sentiments, — these 
are  especially  hurtful  to  a woman  about  the  close  of  her  menstrual 
life. 

Love,  a sentiment  so  gentle  and  so  natural  to  the  female,  a pas- 
sion which  is,  so  to  speak,  the  sole  dominant  passion  of  the  sex,  may, 

* Among  washerwomen  and  other  females  habitually  exposed  to  damp  cold,  the 
cessation  of  the  menses  is,  for  the  most  part,  distressing  and  tempestuous:  such 
women,  likewise,  are  more  liable  than  others  to  leucorrhceal  discharges,  chronic 
inflammations,  and  cancerous  affections  of  the  womb. 


HYGIENE FOR  CHANGE  OF  LIFE. 


551 


at  the  critical  age,  produce  the  greatest  disturbance  in  the  nervous 
system  ; on  this  account,  the  use  of  venery  could  not  be  too  mode- 
rate at  this  period  of  life,  and  should,  in  case  of  the  appearance 
of  any  signs,  be  placed  under  a complete  interdict.  Under  si^ch  cir- 
cumstance, it  is  the  dictate  of  prudence  to  avoid  all  such  circumstances 
as  might  tend  to  awaken  any  erotic  thoughts  in  the  mind,  and  re- 
animate a sentiment  that  ought  rather  to  become  extinct,  such  as  the 
spectacle  of  lascivious  figures,  the  reading  of  passionate  novels,  and 
in  fine,  every  thing  calculated  to  cause  regret  for  charms  that  are 
lost,  and  enjoyments  that  are  ended  forever. 

Most  women  exaggerate  to  themselves  the  dangers  of  the  critical 
age,  representing  the  future  in  the  most  sombre  hues  ; they  should  be 
reassured  upon  this  point,  and  disabused  of  the  false  idea  they  gene- 
rally form  that  their  menses  are  designed  to  purge  the  body  of  some 
virus  or  impure  principle,  and  that  the  cessation  of  the  flow  is  about 
to  become  the  source  of  numerous  disorders.  They  should  be  re- 
minded, that  when  this  short  period  is  once  past,  their  sex  has  a 
better  chance  of  long  life  than  ours.  The  persons  who  live  with 
ijiem  ought  to  turn  aside  their  sad  thoughts,  and  avoid  all  occa- 
sions of  strong  feelings,  and  seek,  indeed,  to  inspire  them  with  none 
but  complacent  affections  : assisted  by  the  counsels  of  medicine  and 
of  friendship  combined,  and  arming  themselves  with  courage  for 
the  conflict,  the  sex  may  hope  to  spend  many  happy  days  far  beyond 
an  age  at  which  they  suppose  there  is  no  further  hope  of  happiness 
for  them. 

How  great  soever  may  be  the  advantages  of  the  hygienic  mea- 
sures we  have  just  proposed,  the  health  of  many  different  females 
still  demands  the  rigorous  observation  of  many  precautions,  and  the 
employment  of  certain  therapeutical  agents,  among  which  we  may 
mention  venesection,  issues,  enemata  baths,  and  purgative  medi- 
cines ; bleeding  is  indicated,  on  account  of  the  plethora  which  gene- 
rally succeeds  the  final  cessation  of  the  menses.  Recourse  should 
be  had  to  it  at  an  early  period,  and  it  should  be  repeated  from  time 
to  time,  and  at  intervals,  greater  or  less,  according  to  circumstances. 
Bleeding  at  the  arm  is  always  to  be  preferred,  because  it  should  be 
rather  derivative  than  spoliative.  Bleeding  in  the  foot  ought  to  be 
rejected  in  these  cases,  as  well,  likewise,  as  the  application  of  leeches 
to  the.vulva  and  thighs.  This  last  method  of  abstracting  blood  is 
objectionable,  as  tending  to  increase  the  local  irritation  and  plethora 
which  it  is  so  desirable  to  remove.  However,  there  are  cases,  very 
rare  ones  to  be  sure,  in  which  leeches  may  be  advantageously 
applied  to  the  hypogaster,  and  even  to  the  vulva ; such  are  the  cases 
where  the  lower  belly  and  the  pelvic  viscera  are  affected  with  acute 
pain,  that  venesection  at  the  arm,  even  when  several  times  repeated, 
has  been  found  incapable  of  alleviating. 

Constipation  ought  to  be  combated  by  the  use  of  injections  sweet- 
ened with  honey,  or  prepared  with  the  addition  of  a teaspoonful  of 
olive  oil.  Suppositories  of  beurre  de  cacao , the  use  of  the  plunge 
bath  and  of  gentle  laxatives,  such  as  Seidlitz  water,  tisans  with 
prunes,  tamarind  whey,  veal  broth  or  vegetable  broth,  infusion  of 


552 


GENERAL  HYGIENE  OF  FEMALES. 


wild  succory,  and  other  drinks  of  the  same  sort,  containing  a weak 
solution  of  sulphate  of  soda,  are  proceedings  to  be  instituted  with 
advantage  to  the  patient.  Drastic  cathartics,  especially  aloetic  pur- 
gatives, ought  always  to  be  rejected,  for  they  excite  the  viscera  of 
the  pelvis,  especially  the  womb  and  the  rectum  too  much,  accumu- 
lating in  that  direction  congestions  that  frequently  lead  to  attacks  of 
metrorrhagia  and  obstinate  haemorrhoidal  disorders.  For  similar 
reasons,  we  ought  to  abstain  from  purgative  injections  irivariably,  as 
well  as  from  hip-baths,  nor  have  recourse  to  common  injections  with- 
out care  in  the  employment  of  them,  and  only  in  cases  of  absolute 
necessity. 

Those  women  who,  in  early  life,  may  have  been  subject  to  swel- 
lings of  the  joints,  or  of  the  lymphatic  ganglions,  to  ophthalmias,  and 
to  cutaneous  eruptions ; and  those,  lastly,  who  happen  to  labour 
under  chronic,  mucous,  or  parenchymatous  inflammation,  &c.,  will 
act  prudently  by  establishing  some  point  of  derivation  upon  the  skin 
by  an  issue,  and  especially  by  a blister.  Petit  Radel  has  justly  re- 
marked, ( Notes  on  Fothergill ,)  that  the  last-named  exutory  is  pre- 
ferable to  the  former  kind,  because  it  acts  upon  a more  extended 
surface,  and  the  irritation  produced  by  it  may  be  easily  increased 
or  diminished.  Let  us  close  by  remarking,  that  the  cessation  of  the 
menses,  which  is  a physiological  phenomenon,  as  natural  as  the  first 
appearance,  would  almost  terminate  well,  were  it  not  that  former 
excesses,  careless  dieting,  and  a treatment  not  unfrequently  foreign 
to  the  principles  of  the  art,  intervene  and  oppose  its  progress.  We 
cannot,  therefore,  too  loudly  proclaim  to  the  sex,  that  infractions  of 
the  laws  of  hygiene  may  lead  them  into  the  arms  of  death  at  a 
period  which  would  have  been  for  them  the  commencement  of  a 
more  tranquil  life,  and  an  existence  exposed  to  much  fewer  dangers. 

GENERAL  HYGIENE  OF  WOMEN. 

Though  the  male  and  female  are  subject  to  the  same  laws  of  life, 
to  the  same  wants,  the  same  passions,  although  the  act  of  living 
ought  to  be  in  common  as  to  the  two  sexes,  there  are,  nevertheless, 
in  the  application  of  the  general  hygiene  of  the  female  certain  shades 
of  difference,  and  pecular  modifications,  in  regard  to  which  we  con- 
sider it  a duty  to  offer  a few  remarks. 

To  proceed  with  a more  regular  method,  and  particularly  that  we 
may  avoid  any  important  omissions,  we  shall  review,  in  succession, 
the  six  classes  that  constitute  the  substance  of  hygiene. 

1.  Circumfusa,  or  surrounding  circumstances.  If  it  be  true,  as 
the  sage  of  Cos  observes,  that  air  is  the  aliment,  the  pabulum  of  life, 
it  also  happens  that  it  may  become  the  aliment  or  cause  of  death, 
in  the  disorder  of  which  it  is  frequently  known  to  be  the  pernicious 
cause ; as  women  are  by  nature  more  sensitive  and  impressionable, 
and  possess  smaller  lungs,  that,  are  more  irritable,  and  more  liable  to 
phthisis,  they  are  of  course  more  injuriously  affected  than  men  are 
by  the  influence  of  atmospheric  vicissitudes.  Precautions  in  regard 
to  the  respiratory  organs  deserve,  in  an  especial  manner,  to  fix  our 


GENERAL  HYGIENE  OF  FEMALES. 


553 


most  particular  attention  at  the  approach  to  puberty,  during  the  act 
of  menstruation,  at  the  change  of  life,  and  in  fact,  at  all  the  epochs  of 
the  life  of  the  female  that  are  characterized  by  an  increase  of  the 
general  susceptibility. 

Women,  particularly  those  in  whom  luxury  and  ease  have  given 
additional  acuteness  to  their  impressionability,  ought,  as  far  as  possible, 
to  inhabit  elevated  apartments ; they  should  avoid  crowded  saloons, 
where  the  air  is  both  too  hot  and  unwholesome ; they  should  be  par- 
ticularly careful  not  to  pass  carelessly  from  a high  to  a low  tempera- 
ture ; when  compelled  to  do  so,  or  to  remain  for  some  time  with  a 
part  of  the  person  unprotected,  they  might  greatly  lessen  the  risk  of 
injury  from  the  sudden  transition  of  temperature  and  from  the  per- 
nicious tendency  of  sudden  cold,  by  stopping  for  a while  in  a cooler 
apartment,  or  by  keeping  up  an  artificial  warmth  by  walking,  or  any 
other  brisk  motion  ; those  who  are  of  a delicate  constitution,  and 
prone  to  catarrhal  and  tuberculous  disorders,  would  act  very  wisely 
by  rendering  their  parenchymatous  organs  and  their  whole  mucous 
system,  and  especially  the  bronchial  and  genital  mucous  membranes, 
less  impressionable,  by  keeping  up  a gentle  excitement  on  the  skin 
by  wearing  flannel  jackets  and  drawers ; they  may  also  weaken  the 
evil  powers  of  dampness  and  cold,  by  using  mild  tonic  drinks,  and 
food  both  nutritious  and  easy  of  digestion. 

The  changes  that  the  constitution  of  the  air  may  undergo  are  some- 
times extremely  hurtful,  especially  to  women.  They  ought,  as  far 
as  possible,  to  interdict  for  themselves  all  places  of  resort  where  great 
numbers  are  assembled,  such  as  balls,  shows,  concerts,  &c.  Without 
dwelling  in  extenso  upon  the  effects  of  exhalations  and  gaseous  efflu- 
via, we  shall  be  satisfied  with  saying,  that  the  habit  indulged  in  by 
some  females  of  surrounding  themselves  with  odours,  deserves  to  be 
mentioned,  on  account  of  the  accidents  and  the  real  dangers  which 
accompany  such  habits.  Nervous  persons  should,  therefore,  not  only 
shun  the  impression  of  powerful  odours,  and  perfumes  even  the  most 
delicate,  but  they  ought  not  to  have  in  their  chambers  flower-pots 
and  vases  filled  with  flowers,  which  are  attended  with  the  double 
inconvenience  of  affecting  the  nervous  sensibility  too  powerfully, 
and  of  decomposing  the  air  by  the  exhalations  of  carbonic  acid  gas. 
Among  the  numerous  cases  in  point  that  we  have  it  in  our  power  to> 
cite,  we  shall  confine  ourselves  to  the  case  related  by  Cromer,  that  of 
the  daughter  of  Nicholas  I.,  Count  of  Salin,  who  died  after  having 
inhaled  the  odour  of  a rose  ; in  1774,  a woman  in  London  was  found 
dead  in  her  bed  in  consequence  of  having  breathed  the  odour  of 
several  full-blown  lilies  that  she  had  placed  in  a small  chamber. 
Triller,  ( Clinotechnia  Medic,  sive  de  diversis  xgrot.  lectis , 1774,) 
saw  a violet  give  rise  to  a distressing  accident : under  nearly  similar 
circumstances,  the  emanations  from  some  lilies  in  blossom  very  nearly 
proved  fatal  to  the  wife  of  Saumonier,  the  distinguished  Rouen  sur- 
geon ; lastly,  on  the  night  of  the  10th  August,  1837,  Mad. , the 

Duchess  d’Ab**'*,  was  upon  the  point  of  being  asphyxiated  from 
having  slept  for  several  hours  in  her  bed-room  where  her  friends  and 


554 


GENERAL  HYGIENE  OF  THE  SEX. 


the  admirers  of  her  literary  talents  had  deposited  their  presents  of 
flowers  on  the  eve  of  her  birth-day. 

From  the  facts  above  related,  it  is  easy  to  judge  that  women  ought 
to  abstain  from  perfuming  their  apartments  with  flowers,  essences  or 
oriental  pastilles,  and  from  carrying  about  their  persons,  perfumery 
and  sweet-scented  bags,  which  are  capable  not  only  of  powerfully 
afl’ecting  the  nervous  sensibility,  but  even  of  acting  as  the  occasional 
causes  of  syncope^  of  asphyxia,  and  a variety  of  spasmodic  disorders 
to  which  the  sex  are  peculiarly  prone. 

Let  us  add  that  the  abuse  of  perfumes  is  attended  with  the  objec- 
tion that  it  may  exalt  or  depress  the  power  of  the  sense  of  smelling, 
and  that  Montaigne  has  judiciously  remarked,  “que  la  plus  exquise 
senteur  dhine  femme , c’est  de  ne  rien  sentir”  bene  olet  quae  nihil 
olet. 

Among  the  most  mischievous  habits  indulged  in  by  females  we 
ought  to  signalize  the  use  of  foot-stoves,  which  disengage  a quantity 
of  carbonic  gas,  and  likewise  excite  the  genital  organs  and  predis- 
pose to  fluor  albus,  and  uterine  haemorrhage,  to  piles,  varix,  ulcers 
on  the  legs,  &c.  Persons  whose  avocations  expose  their  feet  to  cold, 
would  do  well  to  substitute  for  the  foot-stove  a chancelliere  [a  small 
box,  lined  with  bear  skin,  to  put  the  feet  in. — M.]  or  a tin  vase  filled 
with  warm  water. 

2.  Applicata,  or  things  applied  to  the  surface  of  the  body; 
clothing , attention  to  cleanliness , cosmetics , fyc. 

Inasmuch  as  there  is  attached  to  our  clothing  the  precious  advan- 
tage of  guarding  the  body  from  the  immediate  impression  of  the 
atmosphere,  and  thus  of  annulling,  to  a certain  extent,  the  influences 
of  atmospherical  vicissitudes,  it  is  very  important  that  all  parts  of  the 
female  dress  should  be  constructed  with  reference  to  their  manner  of 
life,  the  circumstances  in  which  they  are  placed,  and  the  prevailing 
temperature  of  the  air.  In  winter,  they  should  wear  woollen  stuffs, 
or  silken  stuffs  wadded,  or  doubled,  which,  while  they  are  both  sup- 
ple and  light,  yet  keep  up  a good  degree  of  warmth  about  the  person, 
from  their  being  bad  conductors  of  caloric.  Although  furs  are  pos- 
sessed of  the  same  property,  they  are  inconvenient,  because,  upon 
leaving  them  off  merely  for  a short  time,  the  person  becomes  sensible 
to  the  slightest  cold.  In  summer,  they  should  make  use  of  linen  or 
hemp,  whereas,  in  the  fall  and  spring,  the  variableness  of  the  season 
requires  the  use  of  dresses  that  are  moderately  warm.  Lastly,  at  all 
seasons  of  the  year,  females  ought  not,  without  great  care,  to  lessen 
the  number  of  their  garments,  or  suddenly  change  them  for  others  less 
preservative  against  sudden  changes  of  the  weather.  It  is  equally 
important  for  them  at  all  times  and  seasons  to  keep  the  bosom  and 
the  arms  covered,  and  most  especially  is  it  important  during  the  act 
of  menstruation. 

The  form  of  the  female  dress  also  deserves  attention ; it  should 
always  be  large  enough  not  to  interfere  with  a perfect  freedom  of 
motion,  and  not  to  exert  any  compressing  power  on  the  several  parts 
of  the  body ; the  corset,  especially,  when  badly  constructed,  or  too 


GENERAL  HYGIENE  OF  THE  SEX. 


555 


tight,  interferes  with  the  motion  of  the  body,  prevents  the  expansion 
of  the  lungs,  and  favours  a stagnation  of  blood  in  the  internal  parts 
of  the  body,  disposing  them  to  be  attacked  with  inflammation,  and 
in  consequence  thereof,  with  consumption.  Moreover,  they  painfully 
compress  the  breasts,  and  act  as  causes  of  cancerous  engorgements 
and  indurations.  It  is  but  just,  however,  to  state,  while  the  corset, 
when  too  small,  too  tight,  and  supplied  with  strong  whalebone  and 
a steel  busk,  is  almost  always  hurtful,  the  elastic  corset,  well  fitted 
to  the  shape,  furnished  with  ample  gussets  to  receive  the  breasts 
without  compressing  them,  and  besides  unprovided  with  the  busk 
and  applied  moderately  tight,  lends  grace  to  the  figure,  gives  a useful 
support  to  the  bosom,  increases  the  energy  of  the  muscles  on  the 
chest  and  abdomen,  and,  in  fine,  obviates  a disposition  to  divide,  met 
with  in  some  of  the  muscles,  prevents  the  escape  of  the  abdominal 
viscera  from  the  cavity  of  the  belly,  as  well  as  the  deviations  of  the 
womb,  in  pregnant  and  lying-in  women.  It  should  be  said,  further- 
more, that  a corset,  when  well  made,  ought  to  adapt  itself  to  the  hips 
and  other  parts  of  the  body,  and  not  these  latter  to  the  corset,  as  the 
fashion  required  a few  years  since.  The  use  of  whalebones,  far  from 
being  injurious  in  all  cases,  as  most  authors  consider  them,  is,  on  the 
contrary,  useful,  provided  they  be  made  very  thin  and  flexible,  for 
they  prevent  the  numerous  folds  that  the  various  motions  of  the 
wearer  would  make  in  the  corsets,  and  which,  as  well  as  the  pain 
that  attends  them,  could  be  no  otherwise  prevented  than  by  making 
the  corset  fit  much  tighter  than  when  provided  with  whalebones;  it 
is  right  to  remark,  also,  that  the  shoulder-pieces  ought  to  be  very  large, 
and  especially  very  elastic,  but,  that  although  we  recommend  to  full- 
grown  women  the  use  of  a corset  not  too  tight,  we  look  upon  their 
use,  before  the  age  of  puberty,  as  very  hurtful. 

Frequent  changes  of  clean  linen,  and  strict  attention  to  cleanliness, 
deserve  the  most  scrupulous  attention  of  the  female ; she  ought  to 
take  a tepid  bath  at  least  once  a month,  the  effect  of  it  being  to 
cleanse  the  skin,  render  it  supple,  promote  the  peripheral  circulation, 
excite  perspiration,  and  thus  assist  nature  in  one  of  her  proposed 
ends.  The  temperature  of  the  bath  ought  to  be  so  adjusted  as  to  excite 
a sensation  neither  of  heat  nor  cold ; it  should  simply  be  agreeable. 
This  last  is  always  to  be  preferred  to  that  of  the  thermometer,  which, 
although  it  does  indicate  the  temperature  of  the  water,  yet  it  does 
not  indicate  what  may  happen  to  suit  the  state  of  the  bather.  River 
or  sea  bathing,  in  the  summer  season,  most  generally  agrees  with  the 
constitution  of  the  sex,  but  hip-baths,  which  tend  to  produce  a con- 
gestion of  the  pelvic  viscera,  should  always  be  forbidden,  except 
under  some  special  indication,  of  which  a skilful  physician  alone  is 
the  fitting  judge. 

Among  the  attentions  to  cleanliness,  we  ought  to  place  in  the  first 
rank  those  that  refer  to  the  cure  of  the  sexual  parts.  The  only  liquid  * 
that  a woman  ought  to  use  for  her  toilet , at  all  seasons  of  the  year,, 
except  winter,  is  fresh  water ; in  the  winter  season  it  ought  to  be 
tepid,  that  is,  it  should  be  made  as  warm  as  it  is  in  the  warm  season. 
Very  cold  water  might  produce  inflammation  of  the  vagino-uterine 


556 


GENERAL  HYGIENE  OF  THE  SEX. 


mucous  membrane,  and  thus  bring  on  the  whites,  whereas,  the  fre- 
quent employment  of  tepid  water  is  attended  with  the  risk  of  relaxing 
the  genital  organs,  and  giving  them  a disposition  to  be  affected  with 
haemorrhage. 

For  the  purpose  of  injecting  the  vagina,  it  is  best  to  make  use  of 
a syringe  with  a curved  canula  ending  in  an  olive,  with  several 
holes  in  it ; by  such  an  arrangement  of  the  canula,  the  woman  is 
not  subject  to  too  violent  an  impulsion  of  the  liquid  against  the  os 
tincae.  It  is  just  to  state,  moreover,  that  all  those  toilet  vinegars, 
those  essences,  the  astringent  compositions,  and  all  those  mysterious 
waters  that  the  perfumers  have  the  talent  to  produce,  under  a variety 
of  picturesque  titles,  should  be  proscribed  by  females  who  attach 
any  importance  to  the  conservation  of  their  health ; it  is,  at  the  same 
time,  useful  for  them  to  know,  that  certain  preparations  invented  by 
the  corruption  of  the  public  manners,  and  which  are  the  occasional 
resources  of  mere  libertinism,  are  far  from  equaling  the  precious 
character  of  true  innocence. 

A desire  to  please,  and  to  conquer  all  hearts  by  her  beauty,  has,  in 
all  countries,  and  in  all  ages,  been  one  of  the  most  important  occu- 
pations in  the  life  of  the  female  ; to  attain  this  end,  her  imagination, 
fruitful  in  inventions  of  the  sort,  has  suggested  to  her  various  means, 
in  the  first  rank  of  which  is  the  cosmetic.  These  articles,  which, 
as  their  name  shows,  are  designed  to  embellish  the  skin,  have  fallen 
into  the  hands  of  a set  of  charlatans,  who  have  transformed  them 
into  a thousand  shapes,  more  or  less  prejudicial  to  the  health,  and 
always  useless,  “ pour  reparer  des  arts  V irreparable  outrage 

If  there  really  are  any  cosmetics,  which  are  unattended  with  inju- 
rious effects  upon  the  skin,  such  as  the  aromatic  distilled  waters,  &c., 
the  greater  proportion  of  them,  especially  the  different  sorts  of  rouge , 
and  among  others,  the  red  and  the  white,  compounded  of  metallic 
preparations,  such  as  lead,  mercury,  antimony,  bismuth,  arsenic, 
&c.  &c.,  are  extremely  hurtful,  and  are,  at  the  present  day,  wholly 
abandoned  to  the  use  of  players,  courtesans,  and  a few  old  co- 
quettes. Far  from  producing  the  effects  so  much  wished  for,  these 
various  preparations  are  fit  for  nothing  but  to  precipitate  the  appear- 
ance of  age  ; they  deepen  the  wrinkles,  ruin  the  skin,  arrest  the  per- 
spiration, bring  on  tetter  of  different  sorts,  pimples,  and  erysipelas. 
It  is  true,  that  some  of  them  succeed  in  dispersing  spots,  and  some 
forms  of  cutaneous  eruptions,  but  then  they  are  generally  followed 
by  metastasis  and  repercussion,  that  are  mostly  very  dangerous. 
Salivation,  tremors,  palsy,  convulsions,  colica  pictonum,  ophthalmias, 
inflammation  of  the  stomach,  of  the  liver,  and  the  lungs,  have  been 
the  miserable  consequences  produced  by  the  application  of  various 
metallic  preparations  to  the  skin.  It  is  a duty,  however,  to  observe, 
that  the  rouge , called  vegetable  rouge,  prepared  from  the  carthamus, 
as  well  as  that  extracted  from  red  sanders  wood  infused  in  alcohol, 
from  cochineal,  from  the  root  of  the  alkanet,  Brazil  wood,  and  other 
•vegetable  substances,  is  attended  with  little  danger,  provided  it  be 
seldom  employed,  and  in  moderation.  According  to  Professor  Chaus- 
sier,  the  steatite  may  be  made  use  of,  without  much  inconvenience, 


HYGIENE  FOR  THE  SEX. 


557 


for  the  purpose  of  whitening  and  polishing  the  skin,  and  even  as  a 
preservative  against  certain  contagious  disorders. 

Where  fresh  water,  the  best  and  most  efficacious  of  cosmetics,  will 
not  suffice  to  cleanse  the  skin,  or  restore  its  brilliancy  and  suppleness, 
lost  by  the  abuse  of  pleasures,  prolonged  vigils,  the  use  of  paint,  the 
action  of  the  air,  and  the  solar  rays,  &c.,  the  ladies  may  successfully 
employ  a balsamic  lotion,  prepared  by  mixing  ten  drops  of  balsam 
of  Mecca,  a drachm  of  sugar,  the  yolk  of  an  egg,  and  six  ounces 
of  distilled  rose  water  or  fleurs  de  feve.  She  might,  likewise,  make 
use  of  the  cucumber  ointment,  beurre  de  cacao  ointment,  or  sweet 
almond  ointment,  taking  care  to  get  them  fresh,  and  without  any 
combination  with  the  metallic  salts,  that  certain  perfumers  are  in  the 
habit  of  mixing  with  them. 

Cucumber  ointment,  or  the  salve  made  with  the  same  vegetable, 
and  coloured  with  alkanet,  and  perfumed  with  a drop  of  essence  of 
roses,  is  the  only  article  that  can  be  safely  employed,  either  for 
protecting  the  lips  from  the  irritating  action  of  cold  weather,  or  for 
giving  them  the  vermilion  tint  which  disease  had  deprived  them  of. 
A woman  ought  always  to  refuse  to  employ  the  different  sorts  of 
vinegars  and  spirituous  preparations  that  are  often  recommended  for 
the  same  end.  She  will  do  well,  also,  not  to  use,  without  great 
circumspection,  most  of  the  so-called  treasures  of  the  mouth,  into 
the  composition  of  which  various  acids  are  known  to  enter,  and  the 
presence  of  which  renders  them  quite  injurious  to  the  teeth;*  the 
tincture  of  guaiacum,  the  vinous  tincture  of  bark,  and  the  spirit  of 
cochlearia,  are  the  best  dentrifices  for  the  preservation  of  the  mouth. 
A mixture  of  water  and  alcohol,  with  a few  grains  of  sal  ammoniac, 
may  also  be  very  beneficially  employed,  and  the  powder  of  Peruvian 
bark,  or  charcoal,  or  burnt  bread  incorporated  with  honey,  compose 
an  opiate  which  is  very  suitable  for  whitening  the  teeth,  removing 
the  tartar  that  encrusts  them,  and  thereby  for  preserving  them  from 
the  attacks  of  caries.t  This  opiate  ought  to  be  used  at  least  once  a 
week,  and  it  is  right  to  rinse  the  mouth  after  each  meal,  with  cool 
wine  and  water,  and  to  do  the  same  thing  every  morning,  with  water 
containing  a portion  of  some  one  of  the  liquid  dentrifices  we  have 
mentioned,  or  merely  a little  eau  de  Cologne;  no  one  should  ever 
clean  the  teeth  except  with  a soft  brush,  nor  should  they  take  cold 
drinks  immediately  after  taking  their  food  very  hot. 

The  cosmetics  prepared  for  the  hands,  and  all  the  cutaneous  sur- 
faces, with  a view  to  their  neatness,  consist  of  pastes  and  flour  of 
sweet  and  bitter  almonds,  of  fecula,  and  of  aromatic  soaps.  We 
think  it  a duty,  however,  to  say,  that  the  Windsor  and  Palmyra  soaps, 
which  are  in  most  general  use,  are  but  ill  suited  to  preserve  the  soft- 
ness and  suppleness  of  the  skin,  because  they  always  contain  an 

* Dr.  Regnard,  ( Recherches  sur  la  curie  dentaire , 1838,)  has  proved,  that  the  action 
of  acids  on  the  teeth  is  the  most  common,  and  almost  sole  cause  of  caries. 

■f  M.  Taveau,  a skilful  dentist  at  Paris,  and  author  of  an  excellent  treatise  on  the 
hygiene  of  the  mouth,  makes  a most  successful  use  of  a ciment  obliterique,  for  the 
purpose  of  arresting  caries,  and  curing  pains  of  the  teeth ; it  is  composed  of  anhy- 
drous sulphate  of  alumine,  and  an  alcoholic  and  etherial  extract  of  the  pistachia  len- 
tiscus,  of  the  isle  of  Ohio. 


558 


HYGIENE  FOR  THE  SEX. 


excess  of  alkali,  which  dries,  and  at  last  cracks  it.  None  of  these 
objections  are  chargeable  against  the  liquid  soap,  called  Oleine , pre- 
pared by  M.  Guerlain,  Perfumer,  at  Paris. 

The  caustic  substances  that  enter  into  the  composition  of  depilato- 
ries should  be  sufficient  motive  for  rejecting  their  use ; not  only  may 
they  give  rise  to  serious  symptoms,  but  there  is  the  further  objection 
that  they  do  not  fulfil  the  end  proposed,  for  the  hair  which  they  cause 
to  fall  soon  grows  again.  All  those  metallic  substances  also,  that  are 
used  for  dyeing  the  hair  should  be  banished  from  a lady’s  toilet  as 
being  very  dangerous  articles.  They  mostly  consist  of  nitrate  of  sil- 
ver, or  a mixture  of  sulphuret  of  lead  and  quick-lime,  to  be  diluted 
with  water  at  the  time  of  using  it.  We  add,  as  to  what  relates 
to  the  care  of  the  hair,  that  she  ought  to  confine  herself  to  the 
use  of  the  comb ; to  wash  it  from  time  to  time  with  water,  and  to 
detach  the  dandruff  occasionally  with  a brush,  and,  lastly,  she  should 
tress  it  with  a grace,  and  perfume  it  occasionally  with  some  perfumed 
oil.  We  shall  close  by  reminding  the  ladies  that  too  frequent  dress- 
ing of  the  hair  with  hot  curling  tongs  dries  and  makes  it  early  turn 
gray;  that  metallic  combs  cut  it,  and  that  the  various  pomatums 
recommended  for  improving  the  growth  of  the  hair,  have  no  other 
effect  than  to  cover  it  with  a coat  of  grease  consisting,  for  the  most 
part,  of  coloured  tallow,  perfumed  and  occasionally  mixed  with  oil 
or  beef’s  marrow.  Let  us  observe,  moreover,  that  cleanliness  and 
native  elegance,  the  graces  of  the  body  as  well  as  those  of  the  mind, 
and,  in  fine,  good  temper  and  modesty,  are  the  most  powerful  of 
cosmetics. 

Ingesta.  Food , drinks , &c. — Although  it  be  difficult,  not  to  say 
impossible,  to  trace  out  the  rules  of  alimentary  regimen  applicable  to 
all  women  alike,  we  may  state  that  their  food  ought  to  be  propor- 
tioned to  their  constitution  and  to  the  exercise  they  undergo,  as  more 
or  less  fatiguing.  Their  taste  naturally  inclines  them  to  prefer  such 
dishes  and  beverages  as  are  easy  of  digestion,  and  most  of  them  like- 
wise are  very  fond  of  fruits — preparations  of  milk  and  all  the  lighter 
kinds  of  food,  or  such  as  are  taken  from  the  vegetable  kingdom.  Yet 
some  there  are  who,  giving  way  to  a false  appetite,  have  the  habit 
of  overloading  the  stomach  with  food ; but  it  generally  happens  that 
their  exaggerated  digestive  power  leads  them  to  a state  of  corpulency 
and  excess  of  embonpoint  which,  by  depriving  the  body  of  its  sup- 
pleness, its  activity,  and  all  its  natural  proportions,  are  as  unfavoura- 
ble to  its  beauty  and  its  health,  as  leanness  itself.  There  are  also 
many  women  to  be  met  with  who  are  extremely  addicted  to  the  use 
of  high-seasoned  food  and  to  spirituous  and  aromatic  drinks ; but 
most  of  those  who  thus  transgress  the  laws  of  hygiene  are  found  to 
be  barren,  lean,  of  a bilious  temperament,  and  subject  to  attacks  of 
uterine  haemorrhage,  disorders  of  the  menstruae,  cutaneous  eruptions, 
and  also  to  inflammation  of  the  womb  and  bowels.  Women  who 
desire  to  retain,  during  the  longest  possible  period,  the  advantages 
of  youth,  of  beauty,  and  above  all,  of  health,  should  wholly  abstain 
from  liquors,  stimulating,  acrid  and  spicy  dishes,  from  fat  meats, 
pastry,  and  in  one  word,  from  all  kinds  of  food  artfully  prepared  to 


HYGIENE  OF  THE  SEX. 


559 


exaggerate  the  limits  of  the  appetite,  and  create  factitious  wants. 
Light  kinds  of  food,  derived  from  the  vegetable  kingdom,  meats  of 
easy  digestion,  boiled  or  roast  meats,  fish,  birds  and  game  plainly 
dressed,  milk  in  its  various  preparations,  fruits,  herbaceous  vegeta- 
bles, and  lastly,  water,  either  pure,  or  with  a little  red  wine — such 
should  be  the  constituents  of  diet  for  a woman  from  puberty  to  the 
change  of  life.  We,  moreover,  give  it  as  our  opinion  that  the  frequent 
use  of  tea  and  coffee  is  in  general  hurtful  to  very  nervous  women, 
and  especially  to  those  who  shine  less  by  their  intellectual  qualifica- 
tions than  by  their  beauty  and  all  the  perfections  of  their  merely 
physical  nature. 

4.  Excreta.  Excretion  of  the  menses , the  faeces,  the  urine  and, 
sweat , 8?c. — Our  bodies  so  often  waste  and  repair  the  materials  of 
which  they  are  constituted  that  we  may  compare  one  of  them  to  the 
vessel  of  Theseus,  which  was  so  often  repaired  that  at  length  not  one 
piece  of  its  original  t imbers  was  left.  As  the  condition  of  health  chiefly 
depends  upon  the  perfect  harmony  of  this  double  action,  it  is  easy  to 
understand  why  it  is  of  importance  to  promote,  and  sometimes  to 
moderate  the  different  secretions  of  the  animal  machine.  Women 
should  not  only  follow  out  the  hygienic  rules  we  have  traced  for 
them  in  reference  to  their  menstruation,  but  they  ought  to  pay  a 
special  attention  to  the  excrementitia!  evacuations, to  see  that  they  are 
effected  in  due  proportions,  at  the  periods,  and  by  the  routes  assigned 
for  them  by  nature.  Their  attention  is  chiefly  required  as  to  the 
urinary  and  fascal  evacuations,  that  is  to  say,  they  ought  to  yield  to 
the  first  solicitations  of  the  one,  and  facilitate  the  expulsion  of  the 
other,  by  mild  food,  cooling  drinks,  and  occasionally  by  means  of 
emollient  enemata,  and  by  suppositories,  where  there  happens  to 
arise  a state  of  obstinate  costiveness.  It  is  needful,  also,  to  watch 
with  the  same  scruples,  the  state  of  the  perspiration,  remembering 
that  on  the  one  hand,  too  much  perspiration  brings  on  general  debi- 
lity, and  renders  the  skin  susceptible  to  the  vicissitudes  of  the  weather, 
whilst  on  the  other  hand,  a sudden  suppression  of  the  sweat  occasions 
an  infinity  of  disorders  of  a nature  more  or  less  severe.  To  keep  up 
a gentle  perspiration  of  the  whole  skin ; to  keep  the  person  perfectly 
clean  ; to  dress  moderately  and  suitably  as  to  the  season ; to  abstain 
from  all  immoderate  exercise,  and,  lastly,  to  avoid  sudden  transitions 
from  heat  to  cold ; such  are  the  means  by  which  they  may  keep  up 
a constant  regular  exercise  of  the  functions  of  the  economy. 

5.  Gesta.  Exercise , late  hours,  sleep,  rest,  fyc. — To  keep  her- 
self in  a state  of  health  as  perfect  as  may  comport  with  the  mobility 
of  the  organization,  the  female  should  addict  herself  to  a moderate 
amount  of  exercise,  which  should  end,  however,  as  soon  as  it  becomes 
fatiguing.  All  the  world  knows  that  the  celebrated  Tronchin,  when 
he  was  called  to  the  court  of  Louis  XVI.  and  consulted  by  nervous 
ladies  as  to  their  disorders,  never  recommended  any  thing  but  exer- 
cise, sustained  and  varied  by  all  sorts  of  dissipation.  He  pushed  the 
rigour  of  his  orders  so  far  as  to  prescribe  for  them  the  very  duties 
their  valets  had  been  accustomed  to  perform  for  them;  and  the 


560 


HYGIENE  OF  THE  SEX. 


coquettes  and  high  dames  of  the  court  were  seen  polishing  the  inlaid 
floors,  which  they  had  before  scarce  deigned  to  press  with  their  feet. 

We  ought,  also,  in  this  relation,  to  bring  to  mind  the  inestimable 
value  of  rural  pursuits.  The  aroma  of  plants  and  flowers  exhaled 
at  sunrise,  the  oxygen  which  is  set  free  in  torrents  under  the  influence 
of  light,  the  ravishing  aspect  of  nature,  the  melodious  song  of  the 
birds,  all  serve  to  procure  the  most  delicious  sensations,  and  impart 
to  the  organs  an  incredible  amount  of  strength  and  health. 

Among  the  exercises  to  be  regarded  as  most  suitable  for  females, 
are  those  connected  with  house-keeping,  walking,  as  an  amusement, 
or  as  a prescription,  riding  on  horseback,  jumping,  and  above  all, 
dancing,  provided  it  be  not  continued  to  a late  hour  of  the  night, 
nor  indulged  in  immediately  after  a repast  or  during  the  catamenial 
flow.  The  waltz,  which  has  on  very  good  grounds  met  with  many 
opponents,  conjoins  with  the  disadvantage  of  fatiguing  too  much, 
the  greater  one  of  propelling  the  blood  too  strongly  towards  the 
principal  internal  organs,  and  especially  the 'heart,  lungs  and  brain. 
Speaking,  reading  aloud,  and,  above  all,  singing,  contribute  more 
powerfully  than  might  be  supposed  to  the  conservation  of  the  health, 
and  the  prevention  of  many  affections  of  the  lungs  and  stomach. 
Moderate  exercise,  moreover,  increases  the  appetite,  facilitates  the 
digestion  of  the  food,  energizes  the  circulation  of  the  fluids,  promotes 
the  secretions  and  the  excretions,  and  augments  the  power  and 
activity  of  all  the  systems  of  organs.  When  carried  to  excess,  it  is 
far  from  producing  such  salutary  effects ; for  it  then  exhausts  the 
organs,  reduces  the  strength,  and  renders  all  the  functions  languid. 
In  fine,  leisure,  indolence,  luxurious  habits,  the  soft  and  sedentary 
tone  of  life  which  are  the  very  vices  of  education  among  the  wealthy, 
leave  the  body  in  a state  either  of  debility  or  of  lymphatic  embon- 
point, and  frequently  constitute  the  chief  causes  of  a thousand  nervous 
affections  and  that  excessive  sensibility  which  renders  even  the  gen- 
tlest impressions  absolutely  painful. 

It  is  impossible  to  repeat  too  often,  that  exercise  is  the  surest  anti- 
dote to  the  continued  state  of  suffering  complained  of  by  many  ladies 
in  high  life.  Let  a languishing  coquette,  pale  and  vapoury,  keep 
company  with  strong,  healthy  village  girls,  and  participate  in  their 
labours  as  well  as  their  amusements,  for  awhile  ; she  will  soon  find  in 
herself  a most  admirable  metamorphosis  ! Her  digestion,  which  was 
disordered,  will  be  gradually  restored ; her  strength  will  return  in 
company  with  the  freshness  and  bloom  of  her  complexion  ; indeed, 
her  whole  nervous  system  will  be  corroborated,  and  the  desperate 
languor  and  mobility  which  constituted  a continued  state  of  suffering, 
will  soon  give  place  to  a stable  and  brilliant  condition  of  health. 

Rest,  which  is  as  needful  as  exercise,  should  be  enjoyed  in  proper 
proportion.  Late  hours  are  always  prejudicial  to  the  health  of  the 
sex,  because  they  cannot  repair,  in  the  morning,  the  losses  of  sleep  at 
night,  nor  with  impunity  invert  the  invariable  order  of  nature.  With 
those  among  them,  who,  as  they  say,  turn  night  into  day  and  day  into 
night,  all  the  organs  suffer,  the  functions  are  deranged,  the  nutrition 
is  very  imperfect,  the  physical  constitution  loses  its  energy  entirely, 


HYGIENIC  RULES  FOR  THE  SEX. 


561 


and  the  appearance  and  bloom  of  youth  soon  depart  and  give  place 
to  wrinkles  and  old  age. 

Although  sleep  is  a means  of  restoration,  with  which  nature 
endows  us,  it  ought  not  to  exceed  certain  bounds,  that  is,  it  ought 
not  to  be  prolonged  beyond  from  seven  to  nine  hours.  Sleep  solicited 
by  too  soft  a bed,  plunges  the  nervous  system  into  a sort  of  stupor, 
induces  debility  rather  than  procures  strength,  and  brings  about  a 
fulness  of  the  vessels,  followed  by  torpor  of  the  circulation,  and  not 
rarely  by  haemorrhage.  Upon  the  whole,  the  female  ought  to  retire 
early  to  bed,  be  up  betimes  in  the  morning,  and  pass  her  waking 
hours  in  occupations  that  may  exercise  without  fatiguing  the  organs. 

Percepta,  passions , intellectual  labours , fyc. — Helvetius  says 
“that  the  passions  are  the  celestial  fire  that  vivifies  the  moral  world ; 
it  is  to  them  that  the  arts  and  sciences  owe  their  discoveries,  and  man 
the  elevation  of  his  position.”  It  is  true,  however,  that,  while  some  of 
them  are  useful  to  him,  the  greater  proportion  of  them  agitate  the  cur- 
rent of  his  existence,  fill  it  with  storms,  and  curtail  its  duration.  Their 
influence  upon  his  health  is  questioned  by  none,  whether  they  act 
slowly  or  whether  they  burst  forth  with  impetuous  violence  : in  the 
former,  they  are  like  a concealed  poison  that  destroys ; in  the  latter, 
like  a devouring  flame.  Notwithstanding  that  each  one  of  the  passions 
possesses  a character  peculiar  to  itself,  and  discloses  itself  by  charac- 
teristic signs,  they  all  have  this  in  common,  that  they  pervert  the 
habitual  order  of  the  organs.  The  concentrated  passions,  such  as 
jealousy,  hate,  fear,  envy,  grief,  and  its  varied  forms,  direct  their 
action  principally  upon  the  diaphragm,  the  stomach,  liver  and  womb, 
all  whose  functions  they  are  capable  of  disturbing. 

The  intense  passions,  as  well  as  emotions,  whether  agreeable  or 
painful,  felt  in  excess,  impart  shocks  so  violent  that  the  most  alarm- 
ing symptoms,  and  even  death  itself,  may  be  brought  on  by  them. 
Tissot  knew  a female  at  Lausanne,  who  fell  into  convulsions  when- 
ever the  name  of  her  rival  was  mentioned  in  her  presence.  In  the 
annals  of  France,  we  see  that  a princess  of  Conde  died  of  jealousy, 
on  hearing  that  her  husband  had  attached  himself  to  a lady  of 
honour  to  Catherine  de  Medicis.  Valerius  Maximus  speaks  of  an 
Athenian  lady  who  lost  her  speech  in  an  excess  of  rage;  and  Buchan 
reports  the  case  of  a woman  who  died  suddenly  with  cerebral  hae- 
morrhage, produced  by  a similar  cause.  Lastly,  Professor  Rostan 
saw  a lady  perish  in  the  course  of  two  days,  with  an  attack  of  peri- 
pneumonia, with  which  she  was  seized  upon  reading  a letter  that 
announced  the  death  of  her  son.  Let  us  further  add,  that  a sordid 
interest  led  to  the  sudden  death  of  Leibnitz’s  niece.  That  cele- 
brated philosopher  had  scarcely  yielded  his  last  sigh,  when  his  ava- 
ricious heiress  caused  his  trunks  to  be  opened,  and,  upon  seeing  the 
piles  of  gold  he  had  bequeathed  to  her,  was  so  filled  with  delirious 
joy,  that  she  expired  before  she  could  count  them,  (Elo<*e  de  Leib- 
nitz, by  Fontenelle.)  We  also  observe  that  Cromwell’s  daughter, 
after  the  execution  of  Charles  I.,  was  so  indignant  at  having  for  her 
father  the  assassin  of  her  king,  that  she  died  of  despair.  Although 
the  lively  emotions  and  impetuous  movements  of  the  soul  do  not 
36 


562 


IMPOTENCE  AND  STERILITY. 


always  produce  such  fatal  effects,  they  always  act  in  an  injurious 
manner  upon  the  economy,  and  principally  among  women  whose 
sensibility  and  imagination  are  commonly  of  an  exalted  cast. 

We  conclude  with  remarking,  that  literary  labour,  abstract  studies, 
protracted  meditations,  which,  in  a manner,  concentrate  all  the  vital 
forces  upon  the  organ  of  thought,  are  also  very  prejudicial  to  females. 
Conflicts  of  the  mind  are  especially  hurtful  to  them,  at  the  period 
when  nature  calls  upon  them  to  fulfil  the  important  functions  of  their 
sex,  and  at  an  age  when  they  ought  to  shine  rather  by  the  advan- 
tages and  graces  of  youth,  the  art  of  pleasing  and  the  charms  of  their 
conversation,  than  by  a scientific  or  literary  reputation,  which  men, 
even,  never  purchase  but  at  the  expense  of  both  their  health  and 
their  happiness. 


’SECTION  sixth* 

CHAPTER  XI. 

LESIONS  RELATIVE  TO  REPRODUCTION. 

Lesions  and  sympathetic  phenomena  produced  by  conception,  pregnancy,  labour  and 

lactation. 

In  the  female,  the  lesions  relative  to  reproduction  may  refer  to  her 
as  in  a state  of  conception,  pregnancy,  labour  or  lactation. 

Among  the  lesions  connected  with  conception,  we  may  name  im- 
potence and  sterility,  false  pregnancy,  moles  and  extra-uterine  preg- 
nancy, which  we  shall  here  proceed  to  consider ; and,  first, 


OF  IMPOTENCE  AND  STERILITY. 

With  a view  to  establish  what  we  conceive  to  be  a useful  distinc- 
tion betwixt  impotence  and  sterility,  let  us  make  such  a definition  as 
to  prevent  their  being  confounded  together. 

By  impotence  in  the  female,  we  should  understand  an  inaptitude 
for  conception,  dependent  on  a fault  of  the  physical  condition,  render- 
ing the  accomplishment  of  the  reproductive  act  more  or  less  impos- 
sible. 

Sterility,  on  the  other  hand,  is  an  incapacity,  in  any  woman,  to  con- 
ceive, notwithstanding  that  copulation  may,  in  her  case,  take  place 
in  a natural  manner,  and  be  accompanied  with  all  the  apparent 

* This  is  the  commencement  of  the  third  volume,  or  supplementary  volume,  which 
appeared  in  the  year  1843.  It  was  M.  Colombat’s  intention  to  close  his  labours  with 
the  last  paragraph;  but  I am  happy  to  think  that  he  has  been  enabled  to  bring  his 
task  to  a later  conclusion  by  the  following  fine  essays  on  the  Diseases  of  the  Pregnant 
and  Lying-in  Woman. 


IMPOTENCE  AND  STERILITY. 


563 


conditions  of  fecundation.  From  the  distinction  now  set  up,  it  follows, 
that  a woman  may  be  impotent  without  being  sterile,  and  vice  versa. 

Among  the  causes  of  impotence,  all  of  which  are  connected  with 
some  deformity  of  the  genital  organs,  we  may  enumerate  absence  of 
the  vagina,  primary  or  accidental  obliteration  of  that  tube,  excessive 
contraction  or  undersize  of  it,  produced  by  a deformity  of  the  bones 
of  the  pelvis,  or  by  a tumour  that  cannot  be  removed  ; and,  lastly, 
cohesion  of  the  labia  or  nymphse ; persistence  and  firmness  of  the 
hymen,  or  any  other  membrane  in  the  vagina ; excessive  magnitude 
of  the  clitoris,  and  all  other  deformities  of  structure  preventing  the 
accomplishment  of  the  genital  act,  and  which  may,  often,  be  reme- 
died by  various  operations  that  were  treated  of  in  the  fifth  chapter 
of  this  work.  Let  us  add,  that  prolapsus  of  the  womb  or  vagina,  a 
communication  of  the  vagina  with  the  rectum,  as  well  as  a very 
great  amplification  of  the  size  of  the  vagina,  produced  by  a lacera- 
tion of  the  perineum,  do  not  constitute  absolute  causes  of  impotence. 

The  causes  of  sterility,  a case  difficult  and  often  impossible  to  ascer- 
tain, are,  absence  of  the  womb,  inclination,  incurvation  and  occlu- 
sion of  the  womb ; chronic  inflammation  of  its  texture  and  of  its 
internal  membrane  ; its  spasms,  its  atony  and  its  haemorrhages ; also 
the  absence  of  all  uterine  cavity,  absence  of  the  ovaries,  specific  dis- 
eases of  the  ovaries,  accompanied  with  degeneration  of  their  struc- 
ture, obliteration  and  chronic  inflammation  of  the  Fallopian  tubes, 
and  all  the  disorders  of  the  genital  organs  which  yet  give  no  signs 
leading  to  a suspicion  of  their  existence  during  the  lifetime  of  the 
woman. 

[I  saw,  a few  years  since,  a lady  who  was  attacked  with  symptoms  of 
iiiaca  passio.  Nothing  relieved  her,  and  she  died  with  the  appearance  of 
a person  labouring  under  strangulated  intestine.  Upon  examination,  after 
death,  a knuckle  of  intestine  was  found  to  have  passed  under  a band  within 
the  pelvis,  and  to  have  become  fatally  strangulated  there.  This  was  one  of 
numerous  bridles  which  had  been  produced  many  years  before,  when  this 
lady  was  about  thirteen  years  of  age,  and  suffered  from  an  attack  of  perito- 
nitis, to  which  she  had  nearly  fallen  a victim.  Her  Fallopian  tubes  were 
adherent,  so  as  to  render  their  physiological  function  impossible,  and,  indeed, 
she  had  passed  many  years  in  wedlock,  without  having  conceived.  I sup- 
pose that  young  girls  attacked  with  peritonitis,  ought  to  be  held  very  liable 
to  the  accidental  destruction  of  their  reproductive  power,  by  this  very  adhe- 
sion of  the  tubes. — M.] 

There  are  two  kinds  of  sterility  that  may  be  called  physiological, 
since  they  are  natural  to  all  women : the  first  is  that  which  exists  in 
young  girls  previous  to  puberty,  and  the  second  takes  place  in  women 
who  have  passed  beyond  the  change  of  life.  Women  giving  suck 
are  also  very  often  found  to  be  barren,  and  particularly  during  the 
early  months  that  follow  the  birth  of  the  child,  because  the  vital 
forces  are  then  concentrated  upon  the  organ  of  lactation. 

Sterility  seems  also  to  be  more  common  in  hot  than  in  temperate 


564 


IMPOTENCE  AND  STERILITY. 


and  high  northern  latitudes:  the  abuse  of  baths  and  of  venereal  plea- 
sures are  perhaps  the  causes  of  it.  There  is  not  any  doubt  that 
women  who  abuse  these  pleasures  are  like  the  whole  class  of  prosti- 
tutes, very  subject  to  sterility,  which,  moreover,  is  far  more  common 
in  women  than  among  men.  It  is,  therefore,  not  without  some  show 
of  reason  that  when  a couple,  of  proper  .age,  continue  to  be  without 
offspring,  it  is  the  woman  who  is  generally  accused  of  barrenness. 

Generally  speaking,  sterility  proceeds  from  some  congenital  affec- 
tion ; and,  in  a multitude  of  cases,  the  cause  has  been  supposed 
to  be  discovered.  Among  the  most  common  and  indubitable  of 
these  causes,  is  absence  and  irregularity  of  the  menstruation. 
Notwithstanding,  we  have  reported  some  instances  of  women  con- 
ceiving, though  they  had  never  menstruated,  and  of  others  who  had 
never  menstruated  except  during  their  pregnancy,  it  nevertheless 
holds  true,  notwithstanding  such  rare  facts,  that  the  menstrual  dis- 
charge is  the  most  certain  indication  of  the  aptitude  of  a female  for 
conception. 

A habit  of  excessive  menstruation  has  also  been  regarded  as  the 
cause  of  non-fecundation  in  some  cases;  also,  profuse  leucorrhoea, 
when  habitual.  A painful  sensation,  durante  eoitu  ; absence  of  the 
exterior  attributes  of  the  female  sex,  and  of  voluptuous  desires  and 
sensations,  at  the  conjugal  approaches ; a considerable  embonpoint, 
or  want  of  consonance  betwixt  the  husband  and  wife,  as  to  tempera- 
ment : m fine,  too  violent  and  too  frequently  repeated  transports,  as 
well  as  a constitution  as  to  the  female,  that  resembles  too  closely  that 
of  the  male ; such  as  we  observe  in  tall  women,  with  small  mammae, 
strong  eoarse  voice,  and  brown  skin,  covered  with  hairs  in  places 
usually  destitute  of  them,  in  the  sex. 

While  compelled  to  admit  that  in  certain  cases,  some  of  the  circum- 
stances we  have  now  particularized  really  constitute  conditions  that 
are  unfavourable  to  conception,  ought  we  not,  at  the  same  time,  to 
confess  that  almost  all  the  theories,  as  well  as  the  cases  on  which 
they  are  founded,  are  diminished  as  authority,  by  other  facts  that 
greatly  lessen  the  value  assigned  to  them  by  writers.  Indeed,  do  we 
not  daily  observe  that  women  bring  forth  children,  notwithstanding 
they  may  have  been  subject  to  profuse  menstruation,  or  have  had 
copious  discharges  of  whites,  but  who  are  in  fact  more  liable  to  abor- 
tions and  premature  delivery  than  other  women  are?  Is  not  the 
same  true,  as  to  the  supposed  contrast  betwixt  the  two  spouses,  sus- 
tained with  so  much  vigour  by  Lucretius,  and  especially  by  Bernardin 
de  Saint-Pierre,  with  all  the  power  of  his  poetical  style  and  his  bril- 
liant imagination.  Though  certain  women  are  known  not  to  have 
been  impregnated  by  one  husband,  though  they  have  borne  children 
to  another  one,  ought  we  to  count  for  nothing  the  greater  generative 
power  of  the  last  husband  ; and,  besides,  is  it  not  often  the  case, 
that  a woman  shall  be  sterile  for  a certain  time  only,  and  that  many 
of  them  have  become  pregnant  after  being  several  years  married,  yet 
without  any  change  of  husbands?  Anne  of  Austria  gave  birth  to 
Louis  XIV.  after  twenty-two  years  of  barrenness,  and  Catherine  de 
Med  ids  brought  forth  the  first  one  of  her  ten  children  after  she  had 


IMPOTENCE  AND  STERILITY. 


565 


been  married  ten  years  to  her  husband,  Henry  II.  Is  it  not  also 
known  that  women,  even  such  as  manifest  the  greatest  indifference 
for  their  husband’s  embraces,  or  who  have  been  very  fat,  could  yet 
be  impregnated  by  the  embraces  of  men  of  character,  age  and  tem- 
perament, the  most  various?  Farther,  are  there  not  many  who 
become  mothers,  without  taking  the  least  voluntary  part  in  the  geni- 
tal act,  inasmuch  as  they  had  been  surprised  by  force,  or  had  been  in 
the  lethargy  of  the  profoundest  narcotism  ? 

[I  have  attended,  during  many  years  past,  a considerable  number  of  cases 
of  leucorrhcea,  in  which  the  discharge  consists  of  a small  quantity  of  viscid 
mucus,  coming  away  from  the  genital  organs  at  intervals,  and  not  escaping 
by  a steady  or  continuous  flow.  In  most  of  the  cases,  the  mucus  is  thick, 
translucent,  or  even  transparent,  or  only  slightly  opaque,  and  amounts  to 
about  a teaspoonful.  In  certain  persons,  I have  observed  that  but  one  dis- 
charge took  place  per  diem,  and  that  in  the  afternoon,  leaving  the  patient 
free  from  discharge  during  all  the  rest  of  the  day.  By  using  the  speculum 
uteri,  I have  repeatedly  seen  this  mass  or  lump  of  phlegm  sticking  in  the 
os  uteri,  and  have  removed  it  from  there  with  a bit  of  sponge  : it  is  cohesive 
and  ductile,  so  that  if  caught  upon  the  points  of  the  sponge,  the  whole  mass 
seems  to  be  drawn  out  from  the  cervix. 

I am  of  opinion  that  this  substance  is  produced  by  the  mucous  glandules 
and  follicles  just  within  the  os  uteri;  the  same  that  so  abundantly  secrete  it 
in  the  beginning  of  labour.  Indeed,  the  mucus  of  this  leucorrhcea  is  pre- 
cisely like  that  of  the  dilating  cervix  uteri  in  labour.  I believe  that  all  women 
thus  affected  are  sterile ; at  least,  the  disorder  has  been  invariably  accompa- 
nied with  sterility,  in  my  patients.  The  treatment  by  nitrate  of  silver,  by 
leeches  to  the  os  uteri,  by  alteratives,  astringents,  tonics,  and,  indeed,  by 
whatever  measures,  is  in  general  very  unsatisfactory.  I have,  in  two  cases, 
removed  the  symptoms  by  means  of  the  dilating  bougie,  as  recommended 
by  Dr.  Mackintosh,  in  his  Practice  of  Physic , under  the  head  “ Dysme- 
norrhcea but  my  success,  in  the  use  of  the  bougie,  has  not  equalled  the 
expectations  raised  by  his  publication. 

For  such  a case,  the  occasional  cauterization  of  the  canal  of  the  cervix, 
with  nitrate  of  silver,  or  a pencil  of  sulphate  of  copper,  in  a proper  caustic- 
holder  ; astringent  injections,  bath^,  and  the  total  change  of  the  constitu- 
tional state  produced  by  a long  voyage,  a journey  and  change  of  climate,  afford 
the  most  probable  grounds  of  hope  to  effect  the  cure. — M.] 

From  the  foregoing,  we  ought  to  conclude  that  much  doubt  rests 
upon  questions  concerning  the  causes  of  sterility,  and,  of  course,  that 
we  should  put  numerous  restrictions  upon  all  the  circumstances  that 
are  looked  upon  as  giving  rise  to  it,  and  which  must  always  continue 
to  be  very  obscure,  for  want  of  a rigorous  examination  and  from  the 
impossibility  that  generally  obtains,  of  ascertaining  the  real  state  of 
the  internal  genital  organs  of  the  female.  There  are,  therefore,  no 
certain  signs  by  which  to  distinguish  a barren  from  a fruitful  woman. 


566 


IMPOTENCE  AND  STERILITY. 


Hippocrates,  indeed,  remarks  that  fruitful  women  are  small,  of  dark 
complexion,  menstruating  freely ; that  they  have  well-developed  and 
projecting  breasts,  with  the  womb  dry,  neither  contracted  nor  too 
low.  He  adds  that,  on  the  other  hand,  sterile  women  are  pallid,  do 
not  menstruate  well;  they  are  fat  and  fleshy,  too  ardent  or  too  cold  in 
love,  and  are  generally  troubled  with  leucorrhcea  and  with  headache. 

He  also  says,  (Aphor.  v.  62,)  that  those  who  have  the  womb  cold 
and  dense,  as  well  as  those  who  have  it  moist,  do  not  conceive;  in 
them  the  embryo  perishes  : such  as  have  a very  dry  womb  are  like- 
wise unfruitful,  because  the  semen  is  destroyed  for  want  of  nourish- 
ment. Notwithstanding  all  these  assertions  of  the  father  of  Medicine, 
and  a multitude  of  other  assertions  of  the  same  sort,  what  numerous 
exceptions  do  we  not  find  to  these  general  rules  ; since  we  meet  with 
fruitful  women  of  all  the  various  temperaments,  while  we  also  observe 
a great  many  who  are  barren,  but  who  yet  enjoy  the  most  perfect 
health,  and  the  most  regular  conformation. 

Seeing,  then,  the  great  uncertainty  as  to  the  causes  of  sterility,  we 
may  readily  comprehend  how  inefficacious  must  often  be  the  reme- 
dies proposed  for  its  cure.  The  success  of  these  measures  in  some 
cases  cannot  even  go  to  prove  their  utility,  even  in  those  very  cases, 
inasmuch  as  we  often  observe  that  sterility  disappears  in  women 
long  barren,  without  having  it  in  our  power  to  appreciate  the  cir- 
cumstances which  may  have  restored  the  aptitude  for  fecundation. 

Although,  strictly  speaking,  sterility  is  not  a disease,  it  may  be 
accompanied  by  such  serious  moral  consequences,  that  it  is  important 
to  set  forth  in  this  connection  the  chief  measures  that  have  been  em- 
ployed for  its  removal  under  various  circumstances. 

Treatment . — When  the  barrenness  depends  upon  faulty  confor- 
mation, and  upon  diseases  of  the  womb,  we  may  hope  to  combat  it 
by  remedying  its  deformities  and  curing  its  diseases,  either  by  means 
of  the  different  operations  we  have  pointed  out,  or  by  medical  treat- 
ment appropriate  to  the  disease,  all  of  which  have  been  treated  of  in 
this  work.  It  must  be  unnecessary  to  state  that  in  some  cases  sterili- 
ty is  wholly  incurable. 

If  we  suppose  in  a case,  that  non-fecundation  depends  upon  an 
inclination,  and  particularly  upon  an  anteversion  of  the  womb,  we 
might  recommend  the  coitus  more ferarum^quadr'u'pedumque  ritu, in 
accordance  with  the  advice  given  by  Lucretius.  Further  it  would  be 
proper  in  all  cases  to  recommend  the  sexual  approach  just  before  and 
after  the  mensual  apparition.  This  is  the  moment  when  the  mouth 
of  the  womb  is  open,  and  when  the  organ  has  the  greatest  amount  of 
action,  and  is  therefore  most  apt  for  conception.  It  was  by  giving  to 
Henry  II.  the  counsel,  previously  imagined  for  such  cases  by  Hippo- 
crates, that  Fernel  was  so  fortunate  as  to  procure  for  France  a Dauphin, 
and  to  put  an  end  to  the  sterility  of  the  Queen  Catherine  de  Medicis. 

If  it  be  supposed  that  an  excessive  degree  of  ardour  in  the  genital 
act,  is  the  cause  of  the  sterility,  it  might  be  useful  to  prescribe  an 
emollient  regimen,  baths,  light  food  and  cooling  drinks,  and  especially 
the  use  of  cold  milk,  containing  a teaspoonful  of  lime-water  to  every 
cupful.  Long  walks  and  journeys  could  not  but  be  useful.  In 


STERILITY. 


567 


contrary  circumstances,  that  is,  where  the  woman  is  of  a lymphatic  and 
cold  constitution,  and  remains  indifferent  to  the  conjugal  caress,  we 
might  recommend  country  air,  tonic  and  stimulating  baths,  especially 
the  sea  bath,  chalybeate  and  sulphurous  waters,  such  as  those  of  For- 
ges, of  St.  Alban,  Vichy,  Aix  la  Chapelle,  Bareges  and  Aix  in  Savoy. 
The  patient  would  be  the  better,  likewise,  for  a substantial  diet,  as 
black  meats,  eggs,  a glass  of  generous  wine,  chocolate,  salep,  sago, 
celery,  mushrooms,  truffles,  vanilla,  and  the  various  analeptic  and  ex- 
citing articles.  In  fine,  where  there  exists  a complete  state  of  ana- 
phrodisia,  we  might  advise  the  frequentation  of  the  ball-room,  the 
theatre,  and  even  the  reading  of  romances  and  other  works  of  a some- 
what erotic  character. 

Where  the  female  is  excessively  fat,  attempts  might  be  made  to 
add  to  the  energy  of  the  entire  system,  and  to  reanimate  the  action 
of  the  womb,  by  prescribing  the  internal  use  of  mint,  balm,  garden 
rocket,  saffron,  aloes  or  nutmeg.  These  substances  might  also  be 
used  in  enemata  and  in  injections,  which  should  also  be  recom- 
mended, as  well  as  frictions  of  the  loins,  thighs  and  hypogaster  with 
a hot  flannel,  impregnated  with  oil  of  petroleum,  of  saffron,  or  rue,  or 
with  vapour  of  amber,  benzoin,  or  the  volatile  and  spirituous  sub- 
stances. In  women  of  too  strong  a constitution,  recourse  should  be 
had  to  venesection,  to  tepid  baths,  to  a half-diet,  to  milky  acidulous 
and  cooling  drinks.  Let  us  further  say,  that  where  the  sterility  may 
be  supposed  to  arise  from  any  excess  of  venereal  indulgence,  the 
parties  ought  to  be  separated  for  some  time,  or  at  least  learn  to  have 
some  moderation  as  to  their  sensual  gratifications ; after  this  let  trial 
be*  made  of  tonics,  sedatives  and  an  analeptic  regimen.  It  is  unne- 
cessary to  say  that  cantharides  or  phosphorus  should  never  be  em- 
ployed for  these  ends,  but  with  the  greatest  reserve  and  the  most 
scrupulous  attention. 

[_ Although  not  absolutely  apposite  to  the  subject,  I cannot  refrain  from 
contrasting  with  the  cases  of  special  impotence  and  sterility,  the  remarkable 
productiveness  of  the  human  female  after  the  great  epidemic  of  the  14th 
century,  called  the  Black  Death.  Dr.  J.  F.  C.  Hecker,  in  his  work,  “ The 
Epidemics  of  the  Middle  ages,”  states,  at  page  31,  that  “ After  the  cessation 
of  the  Black  Plague,  a greater  fecundity  in  women  was  everywhere  remark- 
able— a grand  phenomenon,  which,  from  its  occurrence  after  every  destruc- 
tive pestilence,  proves  to  conviction,  if  any  occurrence  can  do  so,  the  preva- 
lence of  a higher  power  in  the  direction  of  general  organic  life.  Marriages 
were,  almost  without  exception,  prolific ; and  double  and  treble  births  were 
more  frequent  than  at  other  times,”  &c.  Dr.  Hecker  computes  the  mortality 
in  Europe  during  the  three  years  of  the  prevalence  of  the  Black  Death  at 
25,000,000  souls. 

It  seems  to  me  that  M.  Colombat  might  have  spared  himself  much 
of  the  foregoing  articles  upon  the  nature,  causes  and  treatment  of  sterility, 
had  he  been  fully  acquainted  with  the  novel  doctrines  on  the  ovum  of 
the  mammalia  to  which  we  have  so  often  referred.  Doubtless  the  tra - 


568 


FALSE  PREGNANCY. 


vail  ovarique  fails  in  many  women  to  produce  the  perfect  ovule,  although 
the  development  of  the  Graafian  cell  may  go  on,  and,  indeed,  in  some  ab- 
normal condition  of  the  vesicle,  as,  for  example,  where  it  becomes  twice  or 
thrice  as  large  as  it  ought  to  be,  we  might  well  suppose  the  elements  of  a men- 
struating power  even  greater  than  the  healthful  one  ; yet  without  developing 
a healthful  ovule,  germinal  vesicle,  or  germinal  macula.  M.  Pouchet,  as 
has  been  seen  at  p.  482,  is  of  opinion  that  the  precise  time  wherein  the  act  of 
fecundation  is  impossible,  can  be  correctly  indicated,  while  it  is  most  proba- 
ble that  the  period  during  which  it  is  most  practicable  cannot  be  so  well 
determined,  since  observation  has  not,  as  yet,  settled  the  question  as  to  the 
date  of  the  rupture  and  discharge  of  the  Graafian  vesicle ; as,  whether 
antecedent  to,  in  the  midst  of,  or  at  the  close  of  the  menstrual  phenomena. 
This,  perhaps,  can  never  be  settled  ; and  it  is  even  probable  that  it  is  a varia- 
ble, not  a constant  period. — M.] 

OF  FALSE  PREGNANCY. 

The  term  false  pregnancy  comprehends  a variety  of  affections  that 
may  simulate  true  pregnancy ; some  of  them  are  always  products  of 
conception,  and  others  are  independent  thereof.  Among  the  former, 
we  include  moles  ; and,  among  the  latter,  we  class  the  cases  of  hy- 
drometra,  of  tympanitis,  of  hydatids  of  the  womb,  polypous,  scirrhous, 
and  cancerous  tumours  of  that  organ,  collections  of  pus,  blood,  me- 
senteric or  epiploic  tumours,  ascites,  and  scirrhus  and  dropsy  of  the 
ovarium. 

Inasmuch  as  we  have,  in  separate  chapters,  traced  the  history  of 
the  disorders  that  may  be  confounded  with  true  pregnancy,  we  shall 
here  be  content  succinctly  to  recapitulate  the  common  considerations 
they  present  in  their  resemblance  to  normal  pregnancy,  to  which 
they  for  the  most  part  conform  only  in  regard  to  the  distensjon  of  the 
abdomen.  It  is  true  that  in  many  of  the  instances  these  affections 
are  coincident  with  suppression  of  the  catamenia,  a suppression 
which  they  may  either  cause,  or  follow  ; and  it  is  also  unquestionable 
that  the  suppression  of  this  evacuation  may  give  rise  to  other  symp- 
toms of  pregnancy,  such  as  enlargement  of  the  breasts,  nausea, 
vomiting,  &c.  Under  these  circumstances  to  commit  an  error  is  so 
very  easy,  that  there  are,  perhaps,  few  medical  men  who  have  not 
witnessed,  or  even  been  subject  to  such  mistakes.  Desormeaux  re- 
lates a case  of  a gross  mistake,  but  of  an  inverse  sort. 

“ A female  living  in  the  Faubourg  St.  Marceau  was  pregnant; 
certain  impudent  quacks  asserted  that  she  laboured  under  dropsy, 
and  plunged  a trocar  into  her  abdomen,  which  killed  her.”  The 
same  author  adds  that  he  was  called  in  consultation  to  decide  as  to 
the  necessity  of  the  Caesarian  operation  for  a woman  who  was  sup- 
posed to  have  been  several  days  in  labour.  She  was  labouring 
under  an  attack  of  intense  peritonitis,  of  which  she  recovered,  but 
she  also  had  a scirrhous  ovarium,  of  which  she  died  some  months 
later  at  the  Alaison  Roy  ale  c/e  Sante. 


FALSE  PREGNANCY. 


569 


Roussel  speaks  of  a woman  in  whom  all  the  signs  of  pregnancy 
were  found,  but  who,  after  the  lapse  of  nine  months,  was  delivered 
of  them  by  a flooding.  Mauriceau  recites  the  case  of  a woman,  fifty 
years  of  age,  who  believed  herself  pregnant,  and  engaged  a midwife 
to  stay  in  the  house  with  her,  and  had  the  baby-clothes  ready — but 
whose  supposed  pregnancy  ended  in  a discharge  of  gas.  Schmidt, 
Lamotte,  M.  Lefevre  and  many  other  persons  tell  us  of  similar  cases. 
In  fine,  we  refer  the  reader  as  to  the  diagnosis  of  the  diverse  affec- 
tions that  simulate  real  pregnancy,  to  our  remarks  in  the  chapters 
on  physometra,  hydrometra,  hydatids,  calculous  concretions,  uterine 
polypus,  and  on  inflammation,  dropsy,  cancer  and  other  degenera- 
tions of  the  ovarium. 

The  collection  of  symptoms  known  as  nervous  pregnancy , or  hys- 
terical pregnancy , which  generally  depends  upon  some  spasmodical 
affection  of  the  abdominal  viscera,  and  which  sometimes  depends 
upon  a chronic  inflammation  of  those  organs,  is  the  form  of  false 
pregnancy  most  commonly  met  with,  and  moreover,  the  one  that 
most  generally  gives  rise  to  mistakes.  For  the  most  part  it  is  met 
with  among  women  approaching  the  change  of  life ; in  women 
affected  with  accidental  suppression  of  the  catamenia,  who  are  ner- 
vous, irritable,  hysterical,  and  particularly  in  the  unmarried  ; further, 
in  widows,  who  imagine  themselves  pregnant  by  a second  husband ; 
and  in  those  who,  having  lost  their  first  children,  are  extremely 
anxious  to  have  them  replaced. 

With  all  these  women,  the  abdomen  swells;  the  menses  cease  to 
appear ; nausea,  disgust,  enlargement  of  the  breasts,  and  in  many  of 
the  cases,  all  the  rational  signs  of  pregnancy  supervene,  so  as  indeed 
to  impose  upon  the  most  skilful  accoucheur,  as  happened  in  fact  to 
Professor  A.  Dubois. 

Under  such  circumstances,  as  well  as  the  others  that  we  have 
described,  an  exact  appreciation  of  the  positive  signs  of  real  preg- 
nancy, and  of  the  signs  peculiar  to  each  of  the  affections  that  might 
simulate  it,  ought  to  enlighten  the  physician,  and  place:  him  in  a 
position  to  decide  as  to  what  kind  of  lesion  the  case  submitted  f m his- 
opinion  belongs.  Furthermore,  the  diagnosis  is  of  still  greater  diffi- 
culty where  pregnancy  is  complicated  with  some  one  of  the  affec- 
tions above  pointed  out;  yet,  from  the  fifth  month  onwards,  the 
careful  exploration  of  the  womb  serves  to  remove  every  doubt,  in 
whatsoever  case  of  false  pregnancy,  and  to  dispel  every  illusion  upon 
the  subject.  In  fine,  the  treatment  of  these  various  affections  is  in 
substance  pretty  much  the  same  as  the  treatment  of  hysteria,  to 
which  we  now  refer  the  reader. 

♦ 

[M.  Colombat  thinks  that  from  the  fifth  month  forward  the  difficulty  of 
diagnosis  is  greatly  lessened,  if  not  removed.  I have  to  say  that  in  cases  of 
ascites  and  anasarca,  the  greatest  embarrassment  is  likely  to  befall  any  man 
who  may  be  called  upon  to  decide  the  question  of  pregnancy,  provided  there 
be  a dead  foetus  in  utero,  floating  in  an  excessive  quantity  of  liquor  amnii, 
while  the  womb  itself  is  drowned  in  a vast  ascitic  effusion.  The  utmost 
precaution  should  be  used  by  the  medical  practitioner,  in  making  the  diag- 


570 


MOLES. 


nosis.  He  ought  not  to  omit  either  the  Touch,  the  abdominal  taxis,  or  the 
stethoscopic  exploration,  nor  should  he  leave  out  of  view  the  commemorative 
and  the  rational  signs  of  pregnancy  connected  with  the  particular  case,  while 
contemplating  the  sensible  signs  of  the  supposed  pregnancy.  Still,  under  cir- 
cumstances like  those  above  proposed,  the  difficulty  is  sometimes  extreme. 
For  my  own  part,  I have  but  one  rule  of  action ; and  that  is,  to  admit  very  can- 
didly my  inability  to  decide,  where  I have  not  the  clear  and  undeniable  signs  of 
a pregnant  womb.  Dr.  Evory  Kennedy,  in  his  valuable  work  on  pregnancy 
and  auscultation,  informs  us  that  the  stethoscope  and  other  means  of  ausculta- 
tion sometimes  reveal  the  heart’s  action  of  the  fcetus  before  the  expiration  of 
the  fourth  month  ; yet,  when  he  has  detected  the  sounds,  they  have  been  “ so 
delicate  and  feeble  as  to  render  it  necessary  for  the  individual  exploring,  to 
have  an  ear  well  trained  to  stethoscopic  sounds.  In  general,  therefore,  we 
may  look  upon  it,  that  this  phenomenon  is  not  to  be  detected  until  after  the 
period  of  quickening,  when  the  uterus  has  risen  out  of  the  pelvis,  and  allows 
of  one  coming  more  immediately  in  contact  with  that  part  of  it  where  the 
embryo  is  contained.” — p.  101.  I may  add,  that  Dr.  Kennedy’s  book  is 
worthy  of  the  perusal  of  every  medical  or  obstetrical  practitioner. — M.] 

OF  MOLES,  OR  DEPRAVED  CONCEPTION. 

There  are  other  kinds  of  false  pregnancy  which  arise  from  a con- 
ception natural  at  the  commencement,  but  the  product  of  which  has 
become  changed  as  to  its  nature,  under  the  influence  of  some  mor- 
bific cause,  and  has  still  further  changed  after  the  death  of  the 
embryo. 

The  productions  that  result  from  these  depraved  conceptions,  have 
received  the  denomination  of  moles,  which  are  distinguished  as  of 
three  kinds,  and,  of  course,  constitute  three  kinds  of  false  pregnancy, 
to  wit,  1,  False  germ  or  embryonal  mole  ; 2,  Fleshy  mole  ; 3,  Hyda- 
tid mole. 

By  the  word  mole,  from  the  Latin  mola , and  the  Greek  \io or 
from  moles , mass,  is  meant  an  organized  fleshy  insensible  body, 
generally  softish,  sometimes  hardish,  of  variable  and  indeterminate 
shape,  which,  after  having  begun  and  having  been  developed  within 
the  womb  is,  instead  of  a foetus,  sooner  or  later  expelled  from  the 
cavity  of  the  organ. 

Moles  have  been  confounded  with  polypus  and  with  the  various 
other  tumours  that  are  produced  within  the  womb ; yet  there  is 
one  very  important  difference  that  distinguishes  them,  which  is  that 
moles  are  always  the  results  of  depraved  conception,  and  products  of 
generation  disturbed  in  its  formation  and  altered  in  its  composition  ; 
while  other  tumours  are  parasitic  bodies,  developed  spontaneously, 
and  without  any  clearly  appreciable  causes. 

Fernel,  the  physician  of  Henry  II.,  was  the  first  author  to  repro- 
duce the  idea  that  a genital  act  is  necessary  for  the  formation  of  a 
mole.  Nusquam  visa  est  mulier  molarn  sine  mare  concepisse. 
This  opinion  was,  at  a later  date,  maintained  by  Mauriceau,  who 


MOLES. 


571 


« 


rested  the  opinion  upon  a number  of  facts,  which  have  never  since 
been  successfully  controverted.  Hippocrates,  Galen,  Aristotle,  Mos- 
chion,  Mercurialis  and  Roderic  a Castro,  supposed  the  mole  to  consist 
in  a mass  of  flesh  developed  in  the  womb  in  consequence  of  an  imper- 
fect conception  ; yet  Hippocrates  speaks  of  certain  bodies  that  grow 
within  the  womb,  in  strong,  robust  young  girls ; and  Galen  avers 
that  in  the  same  way  as  the  hen  may  lay  her  eggs  without  the  tread 
of  the  cock,  so  some  women  may  produce  moles  without  the  inter- 
vention of  the  husband.  Lastly,  Mercurialis  ( De  morb.  mulierum , 
lib.  i.  cap.  4.  p.  24.  1597,)  pretends  that  a voluptuous  dream  has  often 
sufficed  to  give  rise  to  a mole  in  the  womb  of  a young  girl.  Wein- 
rich,  of  Breslau,  thought  that  a mole  might  be  formed  in  the  uterus 
of  a virgin,  or  even  of  a castrated  woman,  [Comment,  de  monstris , 
1595.)  In  fine,  Stalpaart  Van  der  Wiel  described  a virginal  mole, 
( Obs . rariores  medicinal .,  1687,)  and  Hanneman  published  a memoir 
on  the  moles  of  young  girls,  [Ovum  Harv.  gener.  1678);  this  opinion 
is  partly  admitted  by  M.  Velpeau,  who  recognizes  the  possibility  of 
the  mole  in  a virgin,  but  regards  them  as  very  rare. 

With  a view  to  reconcile  all  these  different  opinions,  Lamzeweerde 
[Hist.  Nat.  Molarum  Uteri , 1686,)  distinguished  them  into  moles 
of  generation  and  moles  of  nutrition.  The  same  author  victoriously 
opposed  all  the  ridiculous  prejudices  which  prevailed  in  his  day 
on  the  subject  of  moles,  and  which  some  medical  men  promoted 
by  their  marvellous  histories  of  vital  moles,  and  fantastic  animals, 
living  or  dead,  such  as  screech-owls,  frogs,  lizards,  bats,  dragons, 
apes,  &c.,  brought  into  the  world  by  women.  Some  authors  also 
have  admitted  the  existence  of  true  and  false  moles ; that  is  to  say, 
they  supposed  some  to  be  the  result  of  abortive  conception,  while 
others  had  formed  spontaneously  and  without  any  appreciable  cause ; 
among  the  latter  they  classed  the  wind-mole,  the  water-mole  and  the 
humoral  mole,  which  were  neither  more  nor  less  than  the  disorder 
we  have  described  under  the  heads  of  hydrometra  and  physometra 
or  uterine  tympanitis. 

Whatever  may  be  the  supposed  value  of  these  opinions,  it  is  at 
present  generally  admitted  by  the  pathologists  and  accoucheurs,  that 
a mole  is  the  result  of  a conception  that  has  become  depraved  from 
some  cause,  and  which  is  called  a false  germ,  or  embryonal  mole, 
where  the  product  does  not  remain  more  than  two  or  three  months  in 
the  womb,  and  besides,  exhibits  the  usual  envelopes  of  the  ovum, 
which,  though  always  thicker  and  more  dense  than  the  healthy  ones, 
are  yet  filled  either  with  a transparent  or  a bloody  fluid,  amid  which 
are  discovered  the  early  lineaments  of  the  embryo.  False  germs, 
then,  differ  from  fleshy  moles,  only  as  to  the  longer  sojourn  of  the 
latter  in  the  womb,  and  as  the  membranes  are  both  thicker  and  more 
consistent. 

Fleshy  moles  are  sometimes  hollow  and  sometimes  compact  or 
solid.  In  the  former  the  size  varies  from  that  of  a goose-egg  to  that 
of  a foetal  head  ; the  cavity  is  polished  and  full  of  water,  while  the 
external  surface  is  fungous,  uneven,  rounded,  and  sometimes  lobular 
and  angular.  In  the  latter  case,  which  is  where  the  mole  is  solid,  it 


57 2 % 


HYDATID  MOLES. 


consists  of  a more  irregular  and  larger  mass ; they  are  sometimes 
met  with  of  enormous  dimensions,  but  for  the  most  part  do  not 
exceed  the  size  of  the  double-fists.  Their  texture  is  composed  either 
of  a filamentous  and  spongy  tissue,  like  that  of  the  placenta,  or  of  a 
fleshy  parenchyme  mixed  up  with  clots  of  fibrinous  blood,  amid  which 
are  often  found  incorporated  the  remains  of  embryos,  bones,  and 
even  whole  limbs. 

The  last  circumstance  proves  that  a twin  pregnancy  may  coincide 
with  a fleshy-mole ; but  it  is  very  uncommon  for  both  the  products 
to  be  affected  at  the  same  time,  and  for  two  moles  to  be  simulta- 
neously formed  within  the  womb.  On  the  contrary,  a mole  has  often 
been  found  to  co-exist  with  the  natural  product,  and  at  the  conclusion 
of  the  term  of  gestation,  the  exclusion  of  the  mole  has  immediately 
followed  that  of  the  living  foetus,  or  at  least  it  has  come  away  in  the 
course  of  a few  days  after  the  birth  of  the  child.  In  certain  cases, 
such  a mole  produces  abortion,  or  indeed,  which  is  still  more  rarely 
observed,  it  is  expelled  at  some  period  of  the  pregnancy  earlier  or 
later,  and  the  pregnancy  then  goes  on  through  all  its  stages,  the 
woman  reaching  the  full  term  and  giving  birth  to  a perfect  child. 
It  is  proper  to  say  further,  that  moles  have  been  known  to  remain 
for  years  within  the  womb ; Pierre  Rideux,  grandson  to  the  Regent 
of  the  Montpellier  Faculty,  cites  in  the  Mem.  de  l’ Acad  des  Sci.  for 
1735,  the  case  of  a woman  who  discharged  a very  large  mole  at  the 
age  of  seventy-seven  years. 

It  remains  for  us  to  speak  of  the  third  sort  of  moles,  that  is  to  say, 
the  hydatid  mole,  which  consists  in  a degeneration  of  the  placenta, 
and,  like  the  fleshy  mole  and  the  false  germ,  is  a product  of  conception. 
This  diseased  affection  is  nothing  more  than  the  development  within 
the  placenta,  of  a certain  number,  greater  or  less,  of  cysts, — either 
separate  or  united  together  like  the  berries  of  a bunch  of  grapes. 
This  kind  of  mole,  which  is  very  common,  in  general  attains  a size 
greater  than  the  other  sorts,  and  sometimes  sojourns  for  a great 
while  in  the  uterus,  whence  it  escapes  either  in  mass  or  in  broken 
masses.  For  fuller  particulars  we  refer  to  our  remarks  on  degenera- 
tion of  the  placental  tissue  at  p.  378  of  this  volume. 

The  causes  of  moles,  of  whatsoever  species,  are  always  very  ob- 
scure ; but  it  is  ordinarily  supposed  they  may  be  produced  by  any 
cause  capable  of  disturbing  the  development  of  the  new  being. 
Among  these  causes  may  be  classed  a sudden  fright  or  a lively  emo- 
tion experienced  during  the  genital  act,  or  in  any  of  the  early  days 
of  the  embryonal  life.  A bad  quality  of  the  semen,  and  the  usus 
coitus  during  the  catamenial  excretion,  have  also,  by  some,  been 
looked  upon  as  capable  of  giving  rise  to  this  depravation  of  the  pro- 
duct of  generation.  It  is  unnecessary  to  say  that  all  such  hypotheses 
are  wholly  without  foundation. 

The  diagnosis  of  the  different  species  of  moles,  is  extremely  diffi- 
cult, especially  in  their  earlier  stages  in  the  uterus,  because  the  symp- 
toms characterizing  them  at  that  period,  are  equally  characteristic  of 
true  pregnancy.  In  fact,  as  happens  in  real  pregnancy,  a molar  con- 
ception is  announced  by  suppression  of  the  menses,  swelling  of  the 


MOLES. 


573 


breasts,  tumefaction  of  the  belly,  disgusts,  nausea  and  disorder  of 
most  of  the  functions. 

The  obscurity  becomes  much  less,  when  the  mole  has  remained 
for  several  months  within  the  womb.  Under  such  circumstances,  the 
size  of  the  abdomen  is  greater  than  it  is  at  the  corresponding  stage 
of  real  pregnancy ; it  is  generally  more  painful,  harder,  and  more 
equably  distended.  There  is  no  ballottement,  and  no  spontaneous 
motion  of  a foetus.  The  weight  of  the  womb  appears  to  be  greater 
and  more  fatiguing  than  when  it  contains  a foetus,  and  the  woman, 
who  suffers  from  pain  in  the  loins,  from  dysuria  and  from  lassitude, 
more  than  she  does  in  an  ordinary  pregnancy,  also  feels  something 
like  a ball  falling  about  within  her  as  she  turns  from  side  to  side. 
To  all  the  above  symptoms  should  be  added  the  shrinking  of  the 
breasts,  which  were  at  first  enlarged;  the  secretion  of  a serous  fluid 
in  place  of  milk ; and  lastly,  frequent,  irregular  attacks  of  uterine 
hasmorrhage.  Generally  speaking,  after  the  first  five  months  of 
gestation,  where  the  signs  of  true  pregnancy  are  not  to  be  found, 
and  where  the  local  uneasiness,  as  well  as  the  floodings,  continue  to 
increase,  we  are  authorized  to  suppose  the  symptoms  derivable  from 
the  presence  of  a foreign  body  within  the  womb. 

Previously  to  concluding  what  we  had  to  say  upon  the  diagnosis 
of  moles,  we  shall  offer  a few  remarks  upon  the  distinguishing  cha- 
racteristics of  the  fleshy  and  hydatid  mole. 

In  the  first  place,  the  hydatid  mole  is  much  more  rarely  seen  to 
coexist  with  a normal  embryo  than  the  fleshy  mole,  and  a hydatid 
pregnancy  is  almost  always  longer  than  one  from  a fleshy  mole. 
The  belly  is  also  larger,  although  the  womb  is  in  common  not  so 
heavy  or  hard  as  when  occupied  with  a solid  and  compact  fleshy 
substance.  Lastly,  the  hydatid  is  more  frequently  expelled  in  frag- 
ments or  shreds,  and  at  different  times,  and  the  pains  are  stronger 
and  more  lasting  than  in  the  fleshy  mole,  while  there  is  also  greater 
and  consequently  more  dangerous  flooding. 

Where  the  mole  has  attained  its  maturity,  which  is  generally  the 
case  from  the  fourth  to  the  seventh  month,  the  patient  has  pains  like 
those  of  real  labour;  the  womb  contracts,  its  orifice  becomes  dilated, 
and  the  mass  is  expelled.  The  breasts  then  fill  with  milk,  the  lochia 
follows  in  course,  and  all  the  other  secondary  symptoms  take  place 
as  in  a common  lying-in. 

The  treatment  of  moles  was  formerly  very  complicated;  thus, 
some  of  the  authors,  under  an  impression  that  every  thing  ought  to 
be  done  in  order  to  terminate  its  sojourn  in  the  womb,  were  in  the 
habit  of  prescribing  a host  of  remedies  designed  to  effect  its  detach- 
ment and  discharge.  In  order  to  come  at  this  end,  they  practised 
bleeding  in  the  foot  and  arm,  emetics,  sternutatories  and  drastic 
cathartics,  baths,  emmenagogues,  fumigations  and  stimulating  ene- 
mata.  They  provoked  the  uterine  contraction  by  means  of  pessaries 
containing  savine  powder,  rue,  hellebore,  or  aristolochia,  which  they 
also  administered  internally.  In  fine,  in  order  to  expedite  the  escape 
of  the  mole,  they  advised  the  patient  to  leap,  to  walk  about,  and  to 
go  up  and  down  stairs. 


574 


EXTRA  UTERINE  PREGNANCY. 


The  employment  of  such  measures  as  the  above  is  so  much  the 
more  dangerous  for  the  female,  as  the  signs  of  a mole  are  not  inva- 
riably sufficiently  marked  to  remove  ail  risk  of  mistaking  a true 
pregnancy  for  it. 

The  treatment,  then,  for  the  most  part,  requires  nothing  particular ; 
we  should  wait  until  nature  expels  the  foreign  body,  and  then  we 
extend  the  same  care,  and  make  use  of  the  same  precautions  as  in 
an  ordinary  accouchement.  Nevertheless,  if  in  any  case  the  os  uteri 
were  to  be  sufficiently  open  to  enable  us  to  touch  the  mole,  or  see  it 
by  using  a speculum,  it  would  perhaps  be  useful  to  arouse  the  con- 
tractions of  the  organ  by  administering  doses  of  secale  cornutum.  In 
case  a profuse  flooding  should  come  on,  or  be  frequently  renewed,  we 
ought  to  act  as  in  cases  of  abortion,  or  of  placenta  previa  ; that  is  to 
say,  provided  the  dilatation  would  not  admit  of  the  introduction  of 
the  hand  or  a proper  instrument,  we  should  apply  the  tampon ; and 
should  the  mole  appear  at  the  os  uteri,  we  might  seize  it  with  a pair 
of  Levret’s  pi  nee  a faux  Jerme , or  with  our  uterocep  pincers,  repre- 
sented at  fig.  38,  p.  350.  Where  there  is  no  urgency,  the  opening  of 
the  os  uteri  might  be  favoured,  if  possible,  by  applying  some  bella- 
donna ointment,  and  could  the  fingers  be  introduced  within  the  cer- 
vix, we  ought  to  try  to  get  hold  of  the  mole  and  withdraw  it  in  that 
way.  In  fine,  in  those  very  rare  cases,  where  the  tumour  is  too 
voluminous  to  be  able  to  pass  through  the  orifice  of  the  womb,  it 
might  be  exposed  by  means  of  the  speculum,  and  then  seizing  it  with 
a hook  forceps,  we  should  divide  it  into  several  distinct  fragments. 

For  the  most  part,  all  the  symptoms  disappear  when  the  mole  has 
been  extirpated  or  expelled ; and  beyond  that,  the  treatment  is  the 
same  as  that  appropriate  for  a lying-in  woman. 

OF  EXTRA-UTERINE  PREGNANCY. 

The  development  of  a foetus  and  its  appendages  outside  of  the 
womb,  is  called  extra-uterine  pregnancy,  which  is  divided  into  tubal, 
ovarian,  peritoneal  and  interstitial  pregnancy,  accordingly  as  the  pro- 
duct of  the  conception  is  found  in  the  tube,  the  ovary,  the  peritoneal 
sac,  or  in  a cavity  formed  at  the  expense  of  the  texture  of  the  womb 
itself. 

All  the  ancients  were  ignorant,  of  these  different  species  of  preg- 
nancy, the  history  of  which  does  hot  go  back  beyond  two  hundred 
years ; and,  indeed,  most  of  the  writers  of  that  period  looked  upon 
the  first  published  cases  of  the  kind  as  chimerical. 

The  commonest  and  most  anciently  understood  form  of  extra-ute- 
rine gestation  is  the  tubal  pregnancy ; for,  according  to  Riolan,  Pro- 
fessor of  Anatomy  in  the  reign  of  Louis  XIII.,  a surgeon  saw  a case 
of  the  kind  in  1590,  though  not  much  attention  was  paid  to  it  at  the 
time.  The  same  author,  who  himself  had  an  opportunity  of  seeing 
a case  of  the  sort  in  the  body  of  a washerwoman,  in  the  service  of 
Anne  of  Austria,  says  further  that  a surgeon,  one  of  his  cotempo- 
raries, had  met  with  another  case,  in  the  year  1640.  But,  soon  after 
this  period  Regnier  De  Graaf,  Duvernoy,  Bussiere,  Bianchi,  Louis 


EXTRA-UTERINE  PREGNANCY. 


57  5 


Leger  de  Gouey,  Runge,  Bruyer,  of  Leipzig,  J.  Clark,  Wilson,  Martin, 
Petit,  Chaussier,  and  Messrs.  Bry  de  Bouillon,  Bonnie,  Vallerand  and 
a crowd  of  others,  published  cases  of  tubal  pregnancy  that  could 
leave  no  doubt  upon  the  subject. 

After  the  numerous  experiments  that  have  been  made  to  explain 
the  mechanism  of  conception,  and  the  almost  positive  knowledge 
now  acquired  as  to  that  important  question,  it  becomes  easy  for  us 
to  understand  how  the  arrest  may  happen  of  an  ovule  in  some  point 
of  one  of  the  tubes,  and  so  to  comprehend  the  formation  of  a tubal 
pregnancy.  It  is  also  easy  to  conceive  that  if  the  germ  may  stop  at 
any  point  of  the  tube,  it  is  precisely  in  the  fimbria  that  it  will  be 
most  likely  to  stay,  and  that,  after  the  lapse  of  some  short  time,  it 
will  be  difficult  to  determine  whether  the  pregnancy  is  tubal,  ovarian, 
or  abdominal,  because  the  tumour  will  be  seen  to  be  confounded 
with  the  circumjacent  tissues. 

Ovaric , or  ovarian  pregnancy , is  extremely  rare,  and,  by  some 
authors,  is  not  admitted  to  exist;  M.  Velpeau,  for  example,  who 
thinks  that  the  published  cases  have  not  been  sufficiently  well  de- 
scribed or  studied  incontestably  to  establish  the  existence  of  these 
kinds  of  pregnancy.  Other  persons  have  asserted  their  impossibility, 
on  the  ground  that,  at  the  moment  of  fecundation,  the  membrane  of 
the  ovary  gives  way,  and  that,  besides,  in  the  quite  ancient  cases 
that  have  been  published,  it  was  an  easy  matter  to  confound  these 
cases  with  cases  of  peritoneal  pregnancy,  inasmuch  as  the  science 
of  morbid  anatomy  was  not  in  that  day  so  well  understood  as  at 
present.  Be  this,  however,  as  it  may,  the  first  authentic  case  men- 
tioned in  the  annals  of  the  science  is  one  published  in  1682,  by  St. 
Maurice,  a physician  in  Perigord,  in  Mangetus’s  Bibliotheca  Ana- 
tomica , t.  i.  p.  623.  The  second  case  was  reported  by  Vieussens,* 
who  tells  us  that  Montanier,  a physician  at  Lambesc,  in  Provence, 
being  called  to  a woman  who  died  suddenly,  with  violent  pain  in  the 
abdomen,  examined  the  body  for  the  purpose  of  ascertaining  the 
cause  of  so  strange  a death.  He  found  a foetus,  of  about  two  months, 
in  the  lower  belly,  surrounded  with  a quantity  of  blood,  but  without 
any  lesion  of  the  womb  or  Fallopian  tubes;  but  he  observed  the 
right  ovary  to  be  very  much  enlarged  and  lacerated  at  its  lower 
side,  whence  it  was  clear  that  the  fetus  had  escaped. 

In  the  Memoirs  of  the  Academy  of  Sciences, \ Littre  assures  us 
that  he  found,  in  the  left  ovarian,  a vesicle  containing  a foetus  about 
three  lines  and  a half  in  length.  He  adds,  that  this  fetus  was 
attached  to  the  inner  part  of  the  membranes  of  the  vesicle,  where  it 
was  held  by  an  umbilical  cord,  a third  of  a line  thick  and  a line  and 
a half  in  length. 

Lastly,  the  fourth  case  is  due  to  Varoquier,  anatomical  demonstra- 
tor at  Lille,  who  communicated  it  to  the  Academy  of  Sciences  in 
1756.  Upon  opening  the  body  of  a girl,  thirty  years  of  age,  who 
died  with  a fixed  pain  in  the  left  iliac  region,  he  found  the  ovary 


* Verheyen’s  Anatomy.  De  structura,  et  usu  uteri  et  placentae, 
j-  Memoires  de  l’Academie  des  Sciences,  annee,  1701,  p.  109. 


576 


EXTRA-UTERINE  PREGNANCT. 


on  that  side,  of  the  size  and  shape  of  a hen’s  egg.  Upon  opening 
the  tumour,  about  an  ounce  of  a lymphatic  fluid,  resembling  whey, 
escaped,  in  which  was  floating  a foetus,  somewhat  withered,  but  with 
its  umbilical  cord  and  placenta  still  entire.  The  placenta  was  at- 
tached to  the  top  of  the  substance  of  the  ovary,  with  which  it  Avas 
confounded.  The  foetus  was  two  inches  long,  from  the  top  of  the 
head  to  the  knees.  As  some  cases  have  been  published,  since  those 
now  above  mentioned,  it  follows  that  very  few  practitioners  of  the 
present  day  entertain  any  doubts  as  to  the  fact  that  ovarian  preg- 
nancy has  existed  and  may  exist. 

[It  seems  no  longer  deniable,  that  the  spermatozoid  may,  on  some  occa- 
sions, actually  reach  the  ovary.  Both  Bischoff  and  Martin  Barry  have  dis- 
covered the  animalculac  lying  on  the  surface  of  the  organ,  where  they  could 
have  been  transported  only  through  the  Fallopian  tube.  Bischoff,  in  his 
Entwickelung' s Geschicte , & c.,  p.  21,  states  that  it  was  his  good  fortune  to 
make  the  first  discovery  of  the  kind.  Diese  beobachtung  zumachen,  ist 
mir  endlich  zuerst  gegluckt.  The  first  occasion  of  seeing  this  pheno- 
menon, was  June  22,  1838.  He  exhibited  the  fact  to  many  of  his  friends, 
and  made  a communication,  relative  to  it,  to  a scientific  congress,  assembled 
at  Fribourg  in  the  fall  of  1838 ; since  which  time,  he  has  had  other  oppor- 
tunities of  witnessing  the  same  occurrences.  The  proofs  advanced  by  M. 
Colombat,  and  the  clear  and  undeniable  case  by  Dr.  Granville,  accompa- 
nied with  a beautiful  engraving,  in  the  Lorul.  Phil.  Trans.,  1820,  suffice  to 
set  the  question  at  rest.  There  ought,  moreover;  to  be  no  reluctance  to 
admit  the  fact  of  ovarian  fecundation,  for  those  wdio  believe  in  the  ponte 
periodique  of  the  mammals.  It  is  quite  easy  to  suppose  that  an  ovisac  in 
the  ovary  may  be  opened  in  the  steps  of  the  ponte , without  discharging  the 
ovule  which  is  retained  by  its  tunica  granulosa  or  retinacles.  Such  an 
ovule,  being  fecundated  through  the  rent  or  aperture,  afterwards  closed  by 
being  hidden,  in  some  change  of  place  of  the  ovary,  against  an  intestine  or 
the  anterior  lining  of  the  broad  ligament — the  fecundated  ovule  readily  forms 
its  mesenteric  attachment  there — and  we  have,  in  consequence,  a case  of 
ovarian  gestation.  The  ovule,  when  detected  in  the  tube,  even  long  after  the 
sexual  conflict,  is  found  surrounded  by  zoospersms.  M.  Bischoff  represents 
them  in  several  of  the  figures  given  in  his  elegant  Atlas. — M.] 

The  third  species  of  extra-uterine  pregnancy  is  the  peritoneal  or 
abdominal , which  is  produced  when  the  fecundated  ovule  falls  into 
the  abdomen,  instead  of  entering  the  Fallopian  tube.  It  is  probable 
that  this  accident  is  not  very  uncommon,  and  that  the  reason  why  the 
abdominal  pregnancy  is  not  more  frequent  is,  that  the  greater  part  of 
the  germs  which  escape  in  this  way,  perish  before  forming  their 
attachment  upon  the  serous  membrane  destined  to  receive  them. 

One  of  the  most  authentic  cases  of  pregnancy  of  this  kind  was 
published  by  Courtial,  professor  of  medicine  at  Toulouse.*  The 

* Nouvelles  Observ.  sur  les  os.  Observr.  x. 


EXTRA-UTERINE  PREGNANCY. 


577 


foetus  of  which  he  speaks,  which  was  of  nine  months,  was  found  in 
the  left  side  of  the  abdomen,  situated  with  the  head  downwards,  and 
the  feet  above,  connected  by  the  umbilical  cord  with  the  placenta, 
which  was  itself  attached  to  the  omentum  and  stomach.  It  was  ascer- 
tained, by  examination,  that  the  uterus,  the  ovary  and  the  Fallopian 
tubes  were  free  from  any  laceration,  so  that  no  doubt  could  be  enter- 
tained as  to  the  pregnancy  being  abdominal. 

The  case  by  Jouy,  surgeon  to  the  Hotel-Dieu  at  Paris,  and  re- 
ported by  Dionis,*  is  nearly  similar  to  the  preceding.  The  fetus, 
as  in  that  case,  was  of  nine  months;  it  was  likewise  in  the  left  side 
of  the  abdomen,  in  a cavity  filled  with  sanguineous  fluid ; its  cord,  to 
which  it  was  still  connected,  was  attached  to  the  placenta,  situated 
between  the  mesentery  and  colon ; no  rupture  or  cicatrix  of  the 
womb,  tubes  or  ovary  was  discovered. 

In  1748,  two  physicians  of  Soigny  communicated  to  the  Academy 
of  Sciencest  a nearly  similar  case.  It  concerned  a fetus  which  had 
been  carried  by  the  mother,  in  her  abdomen,  for  thirty  years.  It  was 
found  in  the  right  side  of  the  abdomen,  covered  by  its  membranes, 
which  were  attached  to  the  peritoneum  and  mesentery,  outside  of 
the  uterus.  The  foetus  was  well  formed,  provided  with  hair,  and  had 
two  incisor  teeth  ready  to  protrude.  Besides,  as  in  the  preceding 
cases,  the  womb,  the  tubes  and  the  ovaries  bore  no  traces  of  lesion. 

Cases  anterior  to  those  we  have  just  cited,  have  already  been  pub- 
lished ; amongst  others,  by  Egide  Hertogf  and  Achilles  Pirminius 
Gassarus,§  physician  at  Augsburg,  and  by  Steph.  Manialdus.|| 
Other  cases  of  abdominal  pregnancy  have  also  been  inserted  in  dif- 
ferent journals  or  general  treatises  upon  medicine,  by  Abraham 
Cypriaan,1T  by  Solingen,**  by  James  Brodie  Birbeck,tt  by  Cop- 
ping,If  by  Ch.  Delaunay, §§  and  a number  of  others,  whom  it  would 
take  too  long  to  cite. 

Though  frequently  observed,  the  existence  of  abdominal  pregnancies 
has  been  denied  by  some  physicians,  who  pretend  that  the  peritoneum 
is  not  sufficiently  vascular  to  carry  on  the  development  of  the  ovum, 
and  that  supposed  peritoneal  pregnancies  had  no  doubt  been  con- 
founded with  tubal  pregnancies.  We  reply  to  these  arguments,  that  the 
human  ovum,  provided  with  a simple  epichorion,  generally  adheres  to 
the  peritoneum  by  numerous  vascular  filaments,  constituting  a kind  of 
placenta  formed  of  a collection  of  vessels  united  to  a mass  of  spongy 
material,  in  every  respect  similar  to  that  which  characterizes  the 
human  placenta.  We  may  add,  that  this  species  of  placenta  was 
found  inserted  upon  the  ovary  and  broad  ligament,  by  Kelni  and 

* Anatomie  de  fhomme,  c.  vi.  p.  2.23. 
f Mem.de  TAcad.  des  Sciences,  p.  108,  annee,  1748. 
t Dodon.  Exemp.  Med.  Observ.,  1520,  p.321-328. 

§ Gassarus  died  in  1577. 

||  Comment,  in  Hipp.,  in-8,  1619. 

Epist.  ad  Thomas  Millington,  1700. 

**  Manuale  Med.  Oper.,p.  234. 
tt  Philosoph.  Transactions,  t.  i.  p.224. 

44  Leshe  Auszuge,  t.ii.  p.  321. 

§§  Nouveau  Systeme  sur  la  Generation,  p.  270,  1726, 


37 


57S 


EXTRA-UTERINE  PREGNANCY. 


Lallemant ; upon  the  mesentery  and  peritoneum,  by  Weinhard  and 
Weinknecht ; upon  almost  all  the  abdominal  viscera,  by.  Turnbull ; 
upon  the  stomach,  by  Courtial ; upon  the  colon,  by  Fern  ; in  the  iliac 
fossa,  by  Romieux ; on  the  sacrum,  by  Baudelocque  ; on  the  front  of 
the  spinal  column,  by  M.  Arnault : and,  finally,  on  the  kidneys  and 
intestines  by  M.  Bricheteau.  We  remark  further,  that  the  difference 
between  the  organization  of  the  peritoneum  and  that  of  the  womb 
is  no  reason  for  supposing  that  the  peritoneal  serous  membrane  may 
not  serve  as  point  of  attachment  to  the  placenta.  The  ovum  forms 
adhesions  to  all  the  viscera  with  which  it  is  in  contact ; it  is  a part 
supplied  with  vital  forces, and  which  unites  itself  with  another  part  by  a 
kind  of  action  bearing  some  resemblance  to  the  adhesive  inflammation. 
Changes  similar  to  those  which  occur  in  the  uterus,  after  conception, 
take  place  ; for,  by  the  intervention  of  the  placenta,  a communication 
is  established  between  its  vessels  and. those  of  the  neighbouring  parts, 
which  become  sensibly  dilated. 

The  fourth  species  of  pregnancy,  called,  by  M.  Mayer,  intersti- 
tial, has  not  been  mentioned  by- the  ancients.  In  this  form,  the  foetus 
is  developed  in  the  midst  of  the  fibres  of  the  uterus.  Though  it  has 
been  observed  by  Messrs.  Schmidt,  Albers,  Hederich,  Cams,  Chit, 
Bellemain,  Lartet,  Dance  and  Moulin,  Meniere  and  Dujardin,  it  has 
been  carefully  studied  only  by  Messrs.  Mayer  and  Meckel,  and 
especially  by  M.  Breschet,  who  collected  all  the  authentic  cases  in 
an  excellent  memoir,  which  he  published  in  the  Repertoire  cTAna- 
tomie  et  de  Physiologie  Pathologiques,  1826,  p.  ler.  The  mode  of 
formation  of  interstitial  pregnancy  resting  entirely  upon  hypothetical 
suppositions,  is  still  quite  unknown  : wherefore  we  deem  it  right  to 
pass  over  all  the  anatomical  and  physiological  explanations  of  it 
which  have  been  given.  Lastly,  according  to  some  modern  authors, 
there  is  a fifth  kind  of  extra-uterine  pregnancy,  called  utero-tubal , 
because,  in  this  case,  a portion  of  the  ovum  is  developed  in  the  ute- 
rine cavity,  and  a portion  in  the  Fallopian  tube.  Some  cases  of  this 
kind  have  been  reported  by  Patuna,  Hay,  Herbin,  Hoffmeister,  Lau- 
gier  and  Moudot. 

The  causes  that  produce  these  different  species  of  extra-uterine 
pregnancy,  are  very  difficult  to  ascertain ; nevertheless,  though  they 
rest  upon  hypotheses  merely,  which  are  therefore  of  no  practical 
utility,  either  in  regard  to  the  prophylaxis  or  diagnosis,  we  shall 
bestow  a few  words  upon  them.  It  has  been  the  custom  to  regard 
all  deformities  of  the  Fallopian  tubes  as  capable  of  producing  extra- 
uterine  pregnancy ; their  obliteration,  spasm,  or  faulty  direction ; any 
excess  or  diminution  of  their  length  ; their  anti-peristaltic  movement, 
and  all  anomalies  which  they  may  present  as  to  their  situation  or  con- 
formation. There  have  also  been  classed  amongst  the  causes  of  this 
affection,  thickening  and  anormal  density  of  the  investing  tissue  of 
the  ovule  and  of  the  membranes  of  the  ovary;  too  strong  an  adhesion 
of  the  germ,  and  its  being  situated  too  deeply  or  too  near  to  the  liga- 
ment of  the  ovary.  Astruc  thought  that  unmarried  women,  and 
especially  those  who  pretend  to  be  chaste,  were  more  liable  than 
others  to  pregnancies  of  this  kind.  Kruger,  who  is  of  the  same  opin- 


EXTRA-UTERINE  PREGNANCY. 


579 


ion,  maintained  that  the  ovule  either  remains  in  the  ovary,  is  arrested 
in  the  Fallopian  tube  or  falls  into  the  peritoneum,  because  some  vivid 
emotion,  a sudden  fright,  or  surprise,  seizing  a woman  during  the 
coitus,  or  immediately  after  it,  imparts  a shock  which  reacts  upon  the 
sexual  organs  especially.  A case  by  M.  Lallemant  and  another  by 
Baudelocque  seem  to  confirm  this  idea  of  Astruc  and  Kruger.  In 
fact,  in  one  of  these  cases,  the  extra-uterine  conception  seems  to  have 
been  produced  at  the  moment  when  one  of  the  women  was  seized 
with  terror,  at  hearing  the  turning  of  the  key  which  she  had  impru- 
dently left  in  the  lock,  while  she  was  in  the  arms  of  her  lover ; in 
the  other  case,  the  same  accident  seems  to  have  occurred  at  the 
woman’s  hearing  a sudden  noise  which  caused  her  to  fear  being 
taken  in  flagrante  delicto.  Further,  we  ought  to  remark  that,  as 
nothing  of  the  kind  was  observed  in  the  other  cases,  these  various 
explanations  can  only  be  regarded  as  more  or  less  plausible  hypo- 
theses. 

The  signs  of  extra-uterine  conceptions  are,  in  the  early  months, 
very  difficult  to  appreciate,  since  all  the  signs  of  true  pregnancy  are 
extremely  doubtful  during  the  early  periods.  Thus,  the  persistence 
of  menstruation,  the  nausea,  the  mere  frequent  vomiting,  the  mere 
acute  pains  in  the  hypogastrium,  can  have  but  little  value,  since  they 
are  often  absent  and  not  unfrequently  accompany  true  pregnancy. 
The  same  is  true  of  the  want  of  changes  of  the  breasts,  of  the  non- 
secretion  of  milk;  of  the  irregular  shape  of  the  abdomen;  of  its  more 
rapid  development,  especially  on  one  side  ; of  the  movements  of  the 
foetus  at  an  earlier  date,  and  felt,  too,  through  parietes  which  seem  to 
be  thinner  than  common,  and  of  the  small  size  of  the  uterus ; lastly, 
several  other  signs  of  extra-uterine  pregnancy,  which  are  often 
absent  in  this  condition,  and  which  are  met  with  still  more  frequently 
in  natural  pregnancy.  In  general,  there  is  scarcely  a doubt  as  to  the 
existence  of  an  anormal  conception,  when  the  abdominal  tumour 
has  risen  earlier  than  usual,  above  the  superior  strait,  and  when  it 
is  found  to  be  in  one  of  the  iliac  fossae ; when  the  tumour  seems 
irregular  and  varicose;  when  it  is  the  seat  of  pulsations,  and  when 
it  is  easy  to  detect  the  movements  of  the  foetus  through  the  parietes 
of  the  abdomen,  while  we  ascertain  by  the  Touch,  that  the  weight 
and  volume  of  the  womb  are  very  slightly  increased,  and  that  the 
neck  of  the  organ  is  but  little  shortened,  though  it  has  changed  its 
position,  direction,  density,  and  even  form.  Moreover,  there  is  one 
constant  sign,  which  is,  that  when  the-  woman  has  already  borne 
children,  she  recognizes,  by  the  symptoms,  that  the  pregnancy  is  differ- 
ent from  the  preceding  ones.  In  some  cases,  a blunt  probe,  carefully 
passed  into  the  cervix  uteri,  which  is  generally  considerably  open,  or 
even  the  finger  introduced  into  the  same  cavity,  would  indicate 
whether  the  size  of  the  womb  was  enlarged.  The  Touch  by  the 
rectum  would  also  furnish  valuable  information,  as  also  the  applica- 
tion of  the  stethoscope  over  the  tumour,  which  would  enable  us  to 
hear  the  placental  and  foetal  circulation. 

As  to  the  symptoms  which  may  serve  to  point  out  the  nature  of  the 
extra-uterine  pregnancy,  they  are  more  uncertain  even  than  those  we 


5S0 


EXTRA-UTERINE  PREGNANCY. 


have  just  described.  Nevertheless,  when  the  foetus  is  developed  ill 
the  ovary,  the  uterus  is  more  movable  than  when  it  is  seated  in  the 
Fallopian  tube.  When  the  tumour  is  large,  whether  situated  in  the 
ovary,  Fallopian  tube,  or  peritoneum,  the  uterus  is  equally  immova- 
ble, and  suffers  the  same  displacements.  In  peritoneal  pregnancy, 
however,  the  tumour  is  more  elevated,  more  movable,  and  is  gene- 
rally fixed  in  one  of  the  hypogastric  regions.  Lastly,  we  add  that 
the  diagnosis  becomes  still  more  difficult  when  the  foetus  is  dead, 
and  especially  when  it  has  remained  a long  time  in  the  abdominal 
cavity,  of  which  we  shall  relate  several  examples. 

Extra-uterine  pregnancy  commonly  terminates  before  the  fifth 
month;  Turnbull,  Baudelocque,  Arnault,  Novara,  Delisle  and  Pa- 
tuna,  however,  have  known  it  to  go  nearly  to  the  term  of  gestation. 
Canonico  has  seen  it  at  the  first  month,  Treviranus  at  six  weeks, 
Verheyen,  Baudelocque  and  Vallerand,  at  the  second  month;  Bres- 
chet  and  Mayor  at  the  third,  Blizard,  James,  Ramsbotham  and 
Cruveilhier  at  the  fourth,  Barbaut  from  the  fifth  to  the  sixth,  and, 
lastly,  Starke  at  the  seventh.  In  all  the  cases,  the  patients  have 
been  carried  off  by  hsemorrhage,  either  suddenly,  or  after  a few  days 
of  suffering.  Accidents  of  this  nature  are  characterized  by  acute 
pain,  rapid  debility,  paleness  and  syncope.  At  the  examination  after 
death,  the  foetus  is  found  in  the  abdomen,  amidst  clots  and  fluid  blood, 
and  with  the  placenta  in  the  middle  of  the  broken  cyst.  It  should 
be  remarked  that  the  women  generally  experience  pains  like  those 
of  labour,  and  accompanied  with  all  its  symptoms,  such  as  the  dila- 
tation of  the  cervix  uteri,  discharge  of  sanguineous  glairy  mucus,  and 
very  evident  contractions  even  of  the  womb  and  tumour. 

The  rupture  of  the  cyst  may  be  regarded  as  a sort  of  abortion,  and 
the  escape  of  the  foetus  from  the  cavity  in  which  it  is  contained  being 
the  inevitable  consequence,  the  death  of  the  mother  and  child  is 
almost  certain  to  follow,  because  the  latter  can  be  extracted  only 
through  an  artificial  opening : the  interstitial  pregnancy  alone  some- 
times allows  of  the  removal  of  the  foetus  by  the  natural  passages. 

The  death  of  the  foetus  takes  place  most  frequently  in  the  early 
months,  and  when  this  occurs,  the  health  of  the  female  has  been 
known  to  be  re-established,  and  to  continue  for  a considerable 
length  of  time,  although  bearing  in  her  abdomen  the  product  of  con- 
ception, during  a longer  or  shorter  period  of  years.  The  annals  of 
science  contain  a great  many  cases  of  this  kind.  Abraham  Cypriaan* 
speaks  of  a foetus  which  had  remained  twenty-nine  months  in  the 
abdominal  cavity.  Runget  cites  another  case  in  which  the  foetus 
had  remained  eleven  years  in  the  cavity  of  the  Fallopian  tube. 
Spoering,±  a Swedish  physician,  makes  mention  of  a female  who  re- 
tained her  child  for  thirteen  years  in  the  abdomen,  and  Thomas  Bell§ 
cites  a case  of  twins  which  were  carried  for  twenty-one  months  in 

*Epist.  ad  Thomas.  Lug.  1700. 

f Hamburgher,  etc.,  t.  ix.  cap.  1,  pp.  1 — 18. 

* Abhandlungen,  etc.,  1744,  p.  91. 

§ Edinb.  Med.  Comment.,  t.  ii.  p.  71. 


extra-uterine  pregnancy. 


581 


the  abdomen  of  the  mother.  M.  Mojon*  found  in  the  pelvic  excavation 
of  a female  seventy-eight  years  of  age,  who  died  of  decrepitude,  and 
who  was  the  mother  of  three  children,  a tumour  depending  from  the 
uterus,  and  adherent  to  the  vagina  and  bladder ; it  was  composed 
of  a cartilaginous  cyst  containing  a foetus  completely  ossified,  which 
seemed  to  have  lived  to  the  third  month.  Lastly,  M.  Blauchef  lately 
received  into  his  wards  a woman  of  seventy  years  of  age,  who  had  a 
large  tumour  in  her  left  iliac  fossa,  which  dated  from  more  than  thirty 
years  back.  For  some  time  before  she  came  in,  the  pain  was  very 
severe,  the  abdomen  tense  and  painful  to  the  touch.  The  patient  had 
had  one  child,  when  at  the  age  of  twenty-seven  years ; the  tumour 
made  its  appearance  at  forty  years  of  age,  and  the  menses  ceased  at 
fifty.  She  was  supposed  to  have  an  ovarian  cyst,  but  having  died  on 
the  25th  of  September,  1841,  it  was  found  at  the  autopsy  that  the 
tumour  was  composed  of  the  remains  of  a foetus.  Almost  all  the 
bones  were  still  united  by  ligaments,  and  the  skeleton  was  rolled 
up ; the  pelvis  and  inferior  extremities  occupied  the  posterior  part  of 
the  tumour,  the  occiput  the  anterior,  while  the  head  formed  the 
principal  portion  of  the  mass. 

In  all  the  cases  we  have  now  cited,  the  foetuses  had  undergone  dif- 
ferent alterations ; in  general  they  become  shriveled,  dried  and  mum- 
mified, and  the  cyst  in  which  they  are  contained  thickens,  becomes 
fibrous  and  fibro-cartilaginous,  and  may  remain  in  the  abdomen  with 
the  rest  of  the  product  of  conception  for  a long  time  without  endan- 
gering the  life  of  the  woman.  Sometimes,  however,  the  foetus  be.- 
comes  covered  with  a sort  of  incrustation  and  with  a substance  like 
plaster,  and  this  it  is  that  caused  foetuses  of  this  kind  to  be  formerly 
designated  by  the  name  of  lilhopedia  or  petrified  foetuses.  Such 
was  that  at  Sens  in  1582,  or  lilhopedium  Senonense , which  had 
been  carried  by  its  mother  for  28  years;  that  of  Pont-d-Mous - 
son , in  1659,  which  remained  for  30  years  in  the  body  of  the  female 
who  had  conceived  it;  that  of  Dole  in  1661,  which  remained  for  six- 
teen years  in  the  abdominal  cavity  where  it  had  been  developed,  and 
for  the  account  of  which  we  are  indebted  to  Francois  Bouchard,  pro- 
fessor of  medicine  at  Dole;  lastly,  that  at  Toulouse,  in  1678,  which 
had  remained  for  twenty-five  years  in  the  abdomen  of  its  mother, 
and  which  is  described  in  a letter  by  F.  Bayle,  published  in  1678. 

In  other  cases,  the  cyst  is  converted  into  a true  purulent  abscess ; 
the  foetus  is  decomposed,  and  putrefied,  the  sac  forms  adhesions 
with  the  surrounding  parts,  and  opens  into  the  bladder,  caecum,  colon, 
small  intestine,  rectum  or  through  the  abdominal  parietes  or  perineum. 
When  this  happens,  dangerous  symptoms  almost  always  follow, 
and  an  inflammation  which,  extending  to  the  neighbouring  organs, 
gives  rise  to  violent  fever,  which  is  more  or  leks  rapidly  followed 
by  the  death  of  the  patient.  It  sometimes  happens  that  the  female 
falls  into  a hectic  condition,  in  consequence  of  abundant  suppu- 
ration, while  in  other  cases  the  foetus  is  expelled  in  portions,  the 


* Diction,  des  Sciences  Medic.,  t.  xxvii.  p.  42. 
t Supplement  & la  Gazette  des  hdpitaux,  16  Juin,  1842. 


582 


EXTRA-UTERINE  PREGNANCY. 


cyst  empties  itself  little  by  little,  the  suppuration  gradually  ceases, 
and  the  wound  cicatrizes,  or  at  least  diminishes  to  a fistulous  ulcer, 
less  dangerous  than  inconvenient.  Be  it  as  it  may,  extra-uterine 
pregnancy  is  always  extremely  dangerous,  both  for  the  mother  and 
child,  and  its  most  natural  termination  is  the  rupture  of  the  cyst  and 
the  death  of  the  child. 

The  treatment  and  conduct  to  be  pursued  in  cases  of  extra-uterine 
pregnancy,  present  no  positive  rules,  because  of  the  impossibility  of 
detecting  them  with  certainty  in  the  early  months,  and  from  the 
dangers  incurred  from  the  different  means  that  might  be  employed. 
In  extra-uterine  pregnancies  just  commencing,  and  as  to  whose  exist- 
ence there  is  considerable  uncertainty,  the  employment  of  any  active 
or  dangerous  means  should  be  rigidly  interdicted  ; we  should  confine 
ourselves  to  treating  the  symptoms  and  to  relieving  the  abdominal 
pain  by  means  of  strict  diet,  by  a demulcent  regimen,  by  baths,  by 
enemata,  and  by  emollient  poultices  and  fomentations.  It  is  impro- 
per, generally,  to  do  any  thing  before  the  infant  is  viable , that  is  to 
say,  before  the  seventh  month  of  gestation,  especially  when  the  preg- 
nancy passes  through  its  stages  without  producing  dangerous  symp- 
toms. 

But  when  the  motions  of  the  child  have  become  sensible  both  to  the 
surgeon  and  the  mother;  when  the  form  of  the  foetus  can  be  distin- 
guished through  the  walls  of  the  abdomen ; when  by  auscultation  and 
the  touch,  it  has  been  almost  positively  ascertained  that  the  tumour  is 
formed  by  a foetus,  ought  we  to  interfere,  that  is  to  say,  perform  gas- 
trotomy,  or  should  we  wait  for  the  spontaneous  rupture  of  the  cyst  ? 
In  the  last  case,  the  uterine  haemorrhage  and  consecutive  inflamma- 
tion expose  the  woman  to  the  greatest  dangers.  The  only  remedies 
we  can  oppose  to  these  accidents  are  diet  and  absolute  rest,  refri- 
gerants to  the  abdomen,  sedative  and  cold  drinks,  and  some  other 
means  which  are  of  but  slight  avail.  As  to  the  inflammation,  must 
we  not  fear  increasing  its  intensity  very  much  by  operating  in  such  a 
case  and  by  incising  the  walls  of  the  abdomen  to  extract  the  foetus. 
It  is  difficult  to  know  what  to  advise  under  such  circumstances,  but 
we  believe  that  the  operation  ought  not  to  be  resorted  to  untif  after 
the  symptoms  of  internal  haemorrhage  have  disappeared ; it  would  be 
still  more  prudent,  perhaps,  to  wait  until  the  cyst  and  other  foreign 
bodies,  naturally  carried  towards  the  lowest  part  of  the  abdomen, 
should  have  contracted  inflammatory  adhesions,  so  that  the  seat  of  the 
disease,  being  better  circumscribed,  it  might  the  more  readily  be  unco- 
vered by  an  incision,  which  would  also  cause  the  woman  to  be  ex- 
posed to  less  risk. 

Nevertheless,  if  the  pregnancy,  having  nearly  reached  its  term,  were 
accompanied  by  very  severe  pains,  and  especially  if  the  rupture  of 
the  cyst  had  taken  place  or  were  about  to  occur,  and  if,  moreover,  it 
were  certain  that  the  foetus  was  still  alive,  it  would  become  necessary 
to  perform  gastrotomy,  which,  notwithstanding  the  great  dangers  by 
which  it  is  attended,  does  not  augment  those  which  the  mother  runs 
when  left  to  herself,  while  it  offers  some  chance  of  safety  to  the  child. 
With  the  operation,  the  death  of  both  is  but  too  probable,  and  with- 


GASTROTOMY. 


583 


out  it  nearly  inevitable.  Desormeaux  and  M.  Velpeau  think,  with 
good  reason,  that  gastrotomy  would  offer  a much  better  chance 
of  success,  were  it  not  deferred  until  the  symptoms  of  peritonitis, 
itself  a fatal  disease,  become  developed.  M.  Velpeau  adds,  that 
by  resorting  to  it  earlier,  the  operation  offers  the  greater  chance 
of  success  in  proportion  as  the  pregnancy  is  less  advanced,  and 
that  in  this  condition,  the  probability  of  the  life  of  the  child  is  too 
slight  to  be  considered  and  to  be  placed  against  that  of  the  mother. 
The  authors  who  are  in  favour  of  waiting,  and  who  think  we  should 
leave  to  nature  the  care  of  relieving  herself,  cite  in  support  of  their 
opinion,  the  not  unfrequent  examples  of  foetuses  having  remained  for 
a long  period  in  the  abdominal  cavity,  and  even  where  their  presence 
has  given  rise  to  inflammation,  they  bring  not  less  numerous  cases  of 
women  in  whom  the  pus  has  escaped  exteriorly,  carrying  with  it  the 
remains  of  the  foetus.  Gastrotomy  has  been  objected  to,  moreover, 
on  account  of  the  danger  of  the  operation,  which  requires  a large 
opening  in  the  abdomen,  and  especially  on  account  of  the  inevitable 
haemorrhage  and  escape  of  the  waters  which  result  from  it.  Those 
who  are  of  a contrary  opinion,  and  who  approve  of  the  operation,  say 
that  if  not  performed,  the  child  is  surely  sacrificed,  and  the  mother 
exposed  to  the  greatest  danger ; that  gastrotomy  may  save  the  former, 
while  placing  the  female  in  a more  favourable  position  than  when 
left  to  herself;  and  lastly,  that  when  the  cyst  is  opened  by  an  inci- 
sion, the  effusion  is  to  be  feared  less  than  when  the  rupture  occurs 
spontaneously. 

However  it  may  be  in  regard  to  the  different  opinions  we  have  just 
mentioned,  we  believe  that  the  operation  ought  to  be  performed, 
even  after  the  rupture  of  the  cyst,  and  that  in  general  we  ought  not 
to  wait  until  the  symptoms  of  peritonitis  shall  have  declared  them- 
selves, because  in  that  case  we  are  almost  sure  to  see  the  mother  and 
child  perish,  when,  by  operating  earlier,  we  might,  perhaps,  have 
saved  both. 


OF  GASTROTOMY. 

Gastrotomy,  which  is  not  the  Csesarian  operation,  properly  so 
called,  since  the  uterus  is  not  laid  open,  consists  in  incising  the  in- 
teguments of  the  abdomen  to  an  extent  sufficient  to  allow  of  the  ex- 
traction, through  the  opening,  of  a living  or  dead  child.  The  place 
of  choice  is  to  be  determined  by  the  situation  of  the  tumour,  observing 
the  precautions,  however,  rendered  necessary  by  the  presence  of  ves- 
sels. The  incision  is  made  by  cutting  layer  after  layer,  first  the  skin, 
the  muscles,  the  aponeuroses  and  peritoneum,  and  then  the  cyst  which 
contains  the  foetus.  The  extraction  of  the  foetus  is  to  be  made  by 
seizing  it  by  the  feet.  The  waters  and  blood  which  may  have 
escaped  into  the  peritoneum  must  be  removed  as  far  as  possible,  and 
the  placenta  then  taken  away,  particularly  if  it  be  separated.  A 
portion  of  the  wound  is  to  be  united  by  means  of  the  quill-suture,  in 
such  a way  as  to  leave  an  opening  at  the  lower  angle  sufficient  for 
the  discharge  of  the  pus  and  blood,  and  even  for  the  escape  of  the 


584 


GASTROTOMY. 


placenta,  if  it  has  been  impossible  to  extract  it.  After  the  operation 
is  concluded,  a suitable  position  should  be  given  to  the  woman ; the 
wound  is  to  be  dressed  with  a piece  of  fine  linen,  having  portions  of 
charpie  and  long  compresses  placed  over  it,  the  whole  to  be  kept  in 
place  by  means  of  a moderately  tight  bandage  around  the  body.  The 
subsequent  treatment  consists  in  preventing  as  much  as  possible  the 
inflammation  which  follows  this  dangerous  operation  by  the  use  of 
general  and  local  bleedings,  by  emollient  applications,  by  mucilagi- 
nous and  sedative  drinks,  by  strict  diet,  and  lastly,  by  promoting  the 
discharges  by  means  of  frequent  injections.  If  fortunate  enough  to 
save  the  child,  the  female  should  be  requested  to  suckle  it,  in  order 
to  produce  a determination  towards  the  breasts,  which  is  a powerful 
means  of  derivation. 

If  the  head  of  the  foetus  should  have  become  engaged  in  the  exca- 
vation of  the  pelvis,  so  as  to  make  a distinct  projection  and  seem  to 
be  nearly  bare,  or  covered  at  least  with  so  few  integuments  as  to 
allow  us  to  distinguish  the  sutures  and  fontanelles,  the  vagina  ought  to 
be  incised  at  that  point,  and  the  child  extracted  through  the  passage. 
This  operation,  which  was  performed  by  Colomb,  of  Lyons,  at  the 
fifth  month  of  pregnancy,  and  which  terminated  in  the  death  of  the 
patient,  is  less  dangerous  than  gastrotomv,  because  the  cyst  is  opened 
without  uncovering  the  intestines,  and  without  fear,  therefore,  of  effu- 
sion ; besides,  the  dependent  position  of  the  wound  always  allows 
of  a free  escape  of  the  liquid  matters.  To  add  a few  more  words  in 
favour  of  gastrotomy,  we  will  remark,  that  the  operation  has  been 
performed  with  success  in  cases  in  which  the  foetuses  were  dead,  by 
Abraham  Cypriaan  ( loc . cit.),  by  Solingen  ( loc . cit.),  by  Thomas 
Bell  (loc.  cit.),  by  Breyer  (loc.  cit.),  by  Weinhardt  (loc.  cit.), 
and  by  some  others.  We  shall  conclude  by  saying  that  as  to 
extra-uterine  pregnancies  in  which  the  presence  of  the  cyst  has 
brought  on  inflammation  or  suppuration,  we  should  rest  content 
with  combating  the  accidents  that  may  occur ; with  treating  symp- 
toms; laying  open  deposits  of  pus;  and  enlarging  the  orifices  of 
those  which  have  opened  spontaneously ; we  must  assist  the  escape 
of  the  portions  of  soft  parts  or  of  the  osseous  fragments  which  may  pre- 
sent themselves  at  the  opening,  or  have  formed  themselves  a passage 
in  the  vagina,  rectum  or  bladder,  an  instance  of  which  is  related  by 
Josephi.  Lastly,  the  retention  of  pus  or  decomposed  matters  must 
be  prevented,  by  means  of  baths,  injections,  enemata,  by  a rigid 
diet  or  an  analeptic  regimen,  according  to  circumstances. 

If  we  have  to  do  with  a case  of  stationary  extra-uterine  pregnancy, 
without  complications,  which  can  occur  only  after  the  death  of  the 
foetus,  any  attempt  can  but  aggravate  the  position  of  the  patient,  and 
endanger  her  life,  which  may  sometimes  be  otherwise  prolonged 
through  many  years. 

OF  DISEASES  CONNECTED  WITH  PREGNANCY. 

The  diseases  connected  with  pregnancy  are  either  seated  in  the 
gestative  organ  or  depend  upon  the  influence  of  that  organ  on  the 


ABORTION. 


585 


different  functions  of  the  organism ; that  is  to  say,  they  are  either 
idiopathic  or  symptomatic. 

Amongst  the  former  we  rank  retroversion,  anteversion,  obliqui- 
ties, prolapsus,  hernia,  immobility,  wounds,  haemorrhages  and  abor- 
tions. As  we  have  already  spoken  of  all  these  disorders  while 
treating  of  the  pathological  history  of  the  genital  organs  of  the  female, 
we  refer  our  readers  to  the  chapters  which  are  devoted  to  them,  in 
order  to  take  up  the  subject  of  abortion,  of  which  we  have  not  yet 
treated. 


OF  ABORTION  OR  MISCARRIAGE. 

By  abortion,  ought  to  be  understood  the  expulsion  of  the  foetus 
from  the  mother’s  organs  before  it  has  attained  the  degree  of  develop- 
ment necessary  to  render  it  viable.  What  distinguishes  abortion 
from  premature  labour  is,  that  in  the  latter,  the  foetus,  though  born 
before  term,  has  acquired  an  organization  sufficiently  perfect  to  ena- 
ble it  to  live  when  severed  from  its  mother. 

According  to  Madame  Lachapelle,  abortion  is  more  frequent  at 
six,  at  five,  and  at  three  months,  than  at  any  other  period  of  preg- 
nancy. 

Desormeaux,  agreeing  in  that  respect  with  the  observation  and 
opinion  of  almost  all  authors,  thinks,  on  the  contrary,  that  the 
accident  is  the  more  common  as  the  pregnancy  is  less  advanced. 
Morgagni  has  observed  that  a larger  proportion  of  aborted  em- 
bryos were  male  than  female,  and,  in  this  opinion,  coincides  with 
most  of  the  authors  who  have  written  upon  the  subject. 

The  causes  of  abortion  are  divided  into  efficient  and  determin- 
ing. The  efficient  causes  are  nothing  more  than  the  contractions  of 
the  uterus  and  the  muscular  efforts  of  the  parietes  of  the  abdomen ; 
the  determining  causes  ought  to  be  divided  into  predisposing  and 
exciting.  In  some  women  the  former  causes  act  with  so  much  force 
that  abortion  occurs  spontaneously,  without  appreciable  exciting 
causes. 

Women  most  liable  to  abortion  are  those  of  a nervous,  hysteri- 
cal or  irritable  constitution ; those  who  have  abundant  or  irregular 
menses,  or  who  are  affected  with  leucorrhcea,  syphilis,  scurvy,  rickets, 
dropsy,  cancer  or  organic  disease  of  the  womb ; women  who  have 
too  much  embonpoint,  who  are  lame,  in  whom  the  pelvis  is  badly 
formed,  in  whom  the  womb  is  too  yielding  or  not  sufficiently  so,  or 
who  have  become  pregnant  too  early  in  life;  and,  lastly,  those  hav- 
ing improper  or  insufficient  nourishment,  are  also  more  exposed  than 
others  to  abortions : the  same  is  true  of  those  who  have  an  heredi- 
tary disposition  to,  or  who  have  already  had  several  miscarriages^ 
and,  to  conclude,  those  who  compress  the  trunk  too  violently  with 
corsets,  or  who  make  use  of  very  tight  clothing. 

Amongst  the  predisposing  causes  of  abortion  should  be  ranged 
also,  residence  in  marshy  districts  of  country,  and  certain  consti- 
tutions of  the  atmosphere  which  are  mentioned  by  Hippocrates,  and 
which  have  rendered  abortions  really  epidemic  at  certain  periods; 


5S6 


ABORTION. 


Grown-Hann  speaks  of  an  epidemic  of  this  kind  which  occurred  in 
the  year  1685;  Berthold  and  Beherens  observed  a similar  one  in 
1695,  and  A.  Genselius  another  in  1712,  and  lastly,  Stoll  has  described 
an  epidemic  of  abortions  which  prevailed  at  Vienna  in  1778  and  1779. 
We  observed,  likewise,  that  the  cholera  proved  a frequent  cause  of 
abortion  in  Paris  in  1832;  we  ought,  however,  to  remark  that  we 
took  care  during  that  period  of  two  pregnant  women  attacked  with 
cholera,  who  were  several  times  bled  at  the  commencement  of  the 
disease,  and  who  gave  birth,  in  due  time,  to  strong  and  healthy 
children. 

To  the  predisposing  causes  just  mentioned  must  be  added  those 
which  are  connected  with  the  foetus  and  its  appendages;  for  exam- 
ple, abortion  may  be  a consequence  of  debility,  of  disease,  or  of 
monstrosity  of  the  foetus ; it  may  also  depend  on  slight  adhesions  of 
the  placenta  to  the  internal  surface  of  the  uterus,  on  placenta  praevia, 
on  scirrhous,  hydatid,  varicose  or  aneurismal  degeneration  of  that 
organ  ; on  want  of  proportion  between  it  and  the  foetus,  or  atrophy  of 
its  tissue,  on  too  short  or  too  long  a cord,  and,  finally,  on  any  of  the 
diseases  that  might  prevent  the  proper  development  of  the  embryo 
or  foetus. 

[In  most  of  the  cases  of  abortion  that  I have  seen,  the  embryo  had  been 
long  dead;  whence  I conclude  that  in  a majority  of  the  cases  of  the  acci- 
dent, the  cause  of  the  abortion  was  to  be  found  in  the  death  of  the  em- 
bryo.— M.] 

Although  the  predisposing  causes  just  pointed  out  by  us  may  in 
most  of  the  cases  determine  by  their  single  action  the  expulsion  of 
the  product  of  conception,  constituting  spontaneous  abortion , it  is 
customary  to  attribute  the  accident  almost  always  to  particular  circum- 
stances, which  in  general  pass  for  the  principal  and  exciting  causes. 
Amongst  these,  some  of  which  are  insignificant,  are  yawning,  the  act 
of  having  a dejection,  of  voiding  urine,  and  of  coughing ; different  im- 
pressions, as  joy,  sorrow,  anger,  disappointment ; that  produced  by 
a strong  odour,  by  a candle  just  extinguished,  by  coitus,  and  by  a 
number  of  other  circumstances  which  act  more  powerfully ; such, 
for  example,  as  the  violent  movements  and  succussions  which  occur 
in  dancing,  in  riding  in  a carriage  or  on  horseback,  in  running,  leap- 
ing, crying,  coughing,  sneezing,  vomiting,  and,  to  conclude,  all  sudden 
movements  of  the  body,  and  falls  or  blows  upon  the  abdomen,  but- 
tocks or  loins. 

To  the  exciting  causes  just  mentioned,  we  must  also  add  all  acute 
diseases, . such  as  fevers  and  inflammations,  especially  those  of  the 
womb ; diarrhoea,  dysentery,  colic,  constipation,  strangury,  convul- 
sions and  attacks  of  hysteria  and  epilepsy. 

Amongst  the  exciting  causes  of  abortion,  are  to  be  ranged,  more- 
over, the  use  of  baths,  especially  hip  and  foot-baths,  emetics,  drastic 
purgatives,  particularly  those  of  which  aloes  forms  the  basis ; emme- 
nagogues,  such  as  rue,  savine  and  saffron,  etc.;  blood-letting,  espe- 
cially from  the  foot;  and,  lastly,  the  employment  of  mechanical  means, 
of  acupuncture  and  certain  manoeuvres  acting  directly  upon  the  ovum, 


ABORTION. 


587 


which  have  been  recommended  in  cases  of  deformity  of  the  pelvis, 
but  which,  unfortunately,  are  but  too  often  resorted  to  by  infamous 
people. 

In  general,  when  there  is  no*  disposition  to  abortion,  the  greater 
part  of  the  abortive  remedies  and  occasional  causes  we  have  just  cited 
fail  to  produce  the  expected  result  and  do  not  prevent  the  pregnancy 
from  passing  through  all  its  periods.  Thus  writers  are  filled  with 
cases  which  prove  the  inefficacy  of  baths,  pediluvia,  bleeding  from 
the  foot  and  general  bleeding.  Mauriceau  relates  the  cases  of  two 
pregnant  women,  one  of  whom  was  bled  ten  times  without  aborting: 
the  other  also  reached  the  full  term  of  pregnancy,  notwithstanding 
a frequent  use  of  emetics  and  bleeding.  We  took  care  of  a young 
woman  in  1839  who,  in  the  hope  of  inducing  abortion,  had  caused 
herself  to  be  bled  several  times  by  a sage-femme,  and  whom  we 
found  lying  without  consciousness,  in  a pool  of  blood  escaped  from 
a varix  which  she  had  intentionally  opened  in  one  of  her  legs.  But 
far  from  obtaining  the  result  she  hoped  for,  the  pains  in  the  loins  from 
which  she  suffered  before  this  guilty  attempt  disappeared  entirely, 
and  she  was  brought  to  bed  at  the  proper  time  of  a perfectly  well- 
formed  boy.  Puzos  speaks  of  the  wife  of  an  attorney  who  was  deli- 
vered of  a healthy  child,  although  she  had  been  bled  fourteen  times  in 
the  arm  and  seven  in  the  foot ; Janot  bled  a woman  forty-eight  times, 
which  did  not  prevent  her  giving  birth  to  a healthy  child  at  term. 
Lastly,  Mauriceau  also  speaks  of  a brother  physician  who  likewise 
bled  his  wife  ninety  times  during  a pregnancy.  Astruc  remarks 
with  good  reason  that  if  bleeding,  especially  from  the  feet,  caused 
abortion,  there  would  be  fewer  foundlings  in  the  hospitals. 

[I  saw  a lady  at  the  middle  of  the  third  month,  who  had  uterine  haemor- 
rhage to  the  amount  of  more  than  twenty  ounces,  without  losing  the  embryo. 
I delivered  her  of  a healthy  child  at  full  term. — M.] 

The  same  is  true  of  the  other  causes  of  abortion  ; Mauriceau  re- 
lates the  case  of  a woman  pregnant  at  seven  months,  who,  in  order 
to  escape  from  a fire,  let  herself  slide  from  a third  story ; but  losing 
her  hold  from  fright,  she  fell  upon  some  stones  and  fractured  her 
forearm,  which  did  not  prevent  her  pregnancy  from  reaching  its  term. 
Madame  Lachapelle  cites  the  case  of  a young  sage-femme,  pregnant 
and  affected  with  a contracted  pelvis,  who  threw  herself  down  a stair- 
case in  order  to  bring  on  abortion,  and  thus  avoid  the  Csesarian  opera- 
tion; she  died  a few  days  afterwards,  from  the  effects  of  the  fall,  but 
abortion  did  not  take  place.  We  took  care  of  a washerwoman  preg- 
nant at  six  months,  who  had  contused  her  whole  body  in  a fall  which 
she  met  with  while  carrying  clothes;  the  accident  did  not  prevent  her 
from  reaching  her  term  of  pregnancy.  The  employment,  for  a criminal 
purpose,  of  drastic  purgatives,  of  emetics,  of  the  most  powerful  em- 
menagogues,  as  well  as  the  most  violent  exertions,  has  often  caused 
different  acute  diseases  and  even  death,  without  provoking  the  expul- 
sion of  the  foetus.  Pregnancy  has  been  known  to  go  on,  notwith- 
standing the  presence  of  a polypus  in  the  uterus,  of  the  existence 
of  a cancer  of  the  neck,  or  even  of  a wound  of  that  organ.  Since 


588 


ABORTION. 


causes  of  this  kind  act  so  readily  in  some  cases,  while  they  exert 
no  action  in  others,  we  ought  to  admit  that  in  the  former  there 
existed  predisposing  causes  of  abortion.  We  must  remark,  more- 
over, that  there  is  a predisposition  common  to  all  women,  that  which 
corresponds  to  the  menstrual  periods,  an  epoch  when  a fluxion 
towards  the  womb  is  established  which  disposes  the  ovum  to  become 
detached.  This  explains  why,  in  the  early  months  of  pregnancy, 
miscarriages  are  never  more  frequent  than  at  epochs  coinciding  with 
those  of  menstruation. 

Periodical  abortion,  or  that  which  takes  place  at  nearly  the  same 
period  of  pregnancy,  in  the  same  women,  is  one  which  seems  to 
depend  most  clearly  upon  the  spontaneous  or  menstrual  molimen. 
This  kind  of  abortion  may  be  the  result  also  of  a special  condi- 
tion of  the  uterus,  and  especially  of  one  in  which  the  cavity  of 
the  organ  cannot  extend  beyond  certain  limits.  Moreover,  this  acci- 
dent of  gestation  is  the  more  to  be  feared  in  proportion  as  the  female 
has  already  had  a considerable  number  of  them.  As  to  mechani- 
cal causes  and  criminal  manoeuvres,  those  who  employ  them  gene- 
rally fail  in  their  purpose,  and  succeed  only  in  wounding  the  uterus 
and  bringing  on  disorders  that  may  have  the  most  unhappy  con- 
sequences to  the  unnatural  women  who  demand  them. 

The  symptoms  of  abortion  vary  according  to  the  stage  of  the  preg- 
nancy and  the  nature  of  the  causes  which  have  produced  it.  When 
the  result  of  some  disease  and  during  the  two  first  months  of  gestation, 
it  often  happens  that  the  ovum,  then  of  small  size,  is  suddenly  ex- 
pelled almost  without  pain  or  haemorrhage.  This  kind  of  miscarriage 
scarcely  diflers  from  a slight  attack  of  haemorrhage  or  from  a some- 
what difficult  menstruation.  At  a later  period,  the  expulsion  of  the 
foetus  may  produce  most  of  the  phenomena  of  an  ordinary  labour, 
but  it  is  generally  preceded  by  malaise,  lassitude,  rigors,  languor, 
sadness,  syncope,  sensations  of  cold  about  the  pelvis,  paleness  of  the 
face,  palpitations,  fetid  breath,  swelling  and  dark*colour  of  the  eye- 
lids, anorexia,  nausea,  thirst,  pains  in  the  loins,  and  sensation  of 
weight  about  the  external  genital  organs  and  towards  the  funda- 
ment. To  these  phenomena  should  be  added  elevation  of  the  pulse ; 
falling  of  the  breasts,  which  now  secrete  only  a serous  liquid ; the 
discharge  from  the  vulva  of  a humour  at  first  sanious,  and  then  san- 
guineous, to  which  succeeds  liquid  or  grumous  blood  ; diminution  or 
absence  of  the  movements  of  the  child;  lastly,  falling  of  the  abdomen ; 
uterine  pains  becoming  gradually  stronger  and  more  frequent ; the 
progressive  dilatation  of  the  os  uteri  and  protrusion  of  the  mem- 
branes; the  expulsion  of  the  liquor  amnii,  and  after  a time  the  expul- 
sion of  the  product  of  conception,  which  generally  puts  an  end  to  the 
haemorrhage. 

When  abortion  is  the  result  of  a powerful  disturbing  cause,  it  hap- 
pens sometimes  that  the  action  of  this  cause  is  immediately  followed 
by  an  abundant  hmmorrhage,  which  does  not  cease  until  after  the 
expulsion  of  the  foetus  and  its  appendages,  which  expulsion  is  always 
accompanied  by  lancinating  pains  felt  chiefly  in  the  direction  from 
the  umbilicus  to  the  vulva.  We  should  remark  that  in  general  the 


ABORTION. 


589 


, symptoms  of  abortion  resemble  those  of  labour  the  more  closely  in 
proportion  as  the  pregnancy  is  more  advanced ; the  same  is  true 
as  to  the  sequelae,  that  is  to  say,  the  lochial  discharge  and  milk- 
fever.  In  some  cases,  however,  the  effusion  of  blood  produced  by 
abortion  depending  upon  an  exciting  cause  is  preceded  by  pains,  by 
weight  in  the  loins,  by  malaise,  by  rigors  and  by  a sensation  of  unu- 
sual weight  in  the  sexual  organs. 

Although  the  escape  of  blood,  and  more  especially  that  of  the  waters, 
is  always  a symptom  of  threatened-abortion,  the  first  of  these  phe- 
nomena has  often  been  seen,  and  the  second  even  has  been  observed, 
without  abortion  taking  place.  We  attended,  in  the  month  of  Sep- 
tember, 1S39,  the  Baroness  of  Chab  * * *,  pregnant  at  seven  months, 
who,  after  a fall,  was  attacked  with  pains  extending  from  the  umbi- 
licus towards  the  vulva,  and  with  a considerable  hemorrhage,  fol- 
lowed by  the  discharge  of  the  waters ; in  spite  of  all  these  precursory 
phenomena,  the  lady  reached  the  term  of  her  pregnancy,  and  gave 
birth  to  a healthy  child.  A bleeding  at  the  arm,  repose,  cold  and 
sedative  drinks,  an  antispasmodic  and  astringent  mixture,  restored 
every  thing  to  order  and  dissipated  the  symptoms  of  threatened 
abortion. 

Morlanne  cites  the  case  of  a female  who  was  not  delivered  until  six 
weeks  after  the  waters  had  escaped.  M.  Velpeau  relates,  by  the 
authority  of  another  physician,  the  case  of  a female  pregnant  at  six 
months,  in  whom  the  bag  of  waters  was  formed,  and  then  broke*  so 
that  the  arm  of  the  child  engaged  in  the  vagina ; after  this  the  labour 
was  arrested,  the  foetus  resumed  its  position,  and  the  pregnancy  pur- 
sued a regular  course.  M.  Velpeau  adds  that  the  author  both  saw 
and  touched,  and  that  he  ought  to  be  believed.  It  is  proper  to  know, 
also,  that  the  serous  fluid  which  escapes  from  the  cervix  uteri  may 
come  from  an  hydatid  cyst  or  from  between  the  membranes ; it  may 
also  come  from  a double  pregnancy,  in  which  one  ovum  is  broken 
while  the  other  remains  perfect.  Nevertheless,  rupture  of  the  mem- 
branes and  discharge  of  the  waters  indicate,  almost  always,  approach- 
ing abortion,  or  at  least  the  death  of  the  foetus. 

It  is  likewise  necessary  to  know  how  to  distinguish  the  haemorrhage 
which  precedes  a miscarriage  from  that  which  is  the  result  of  a re- 
turn of  the  menses; — in  the  former  case,  the  blood  is  seldom  so  abun- 
dant or  so  apt  to  clot,  and  especially  to  escape  in  this  form  from  the 
genital  organs,  as  when  it  is  the  product  of  an  uterus  occupied  by  a 
foetus  about  to  be  detached. 

It  is  also  very  important  to  distinguish  uterine  pains  from  the 
colics  produced  by  difficult  menstruation.  In  abortion,  the  pains 
follow  the  discharge  of  blood,  while,  on  the  contrary,  they  precede  it 
in  menstruation.  We  should  remark,  moreover,  that  the  touch  will 
often  greatly  assist  in  making  the  diagnosis,  and  especially  in  esta- 
blishing the  fact  of  pregnancy. 

If  the  foetus  has  ceased  to  live,  it  is  generally  soon  expelled  from 
the  uterus ; in  some  cases,  however,  its  expulsion  does  not  occur  until 
after  a longer  or  shorter  period  of  time.  If  the  membranes  remain 
unbroken,  and  especially  if  no  air  has  penetrated  the  uterus,  the 


590 


abortion. 


foetus  may  remain  unchanged  for  several  months,  and  even  years ; 
sometimes  it  becomes  decomposed,  and  passes  into  the  state  of  adi- 
pocire,  as  happens  in  extra-uterine  pregnancy.  In  the  early  months, 
it  often  becomes  atrophied,  and  offers  the  dimensions  of  an  embryo  of 
a month  or  six  weeks  only,  though  the  female  be  pregnant  at  several 
months.  In  some  cases  it  is  macerated  in  the  fluids,  and  the  hard  and 
soft  parts  of  the  embryo  have  been  known  to  disappear  completely, 
and  the  ovum  to  be  transformed  into  a true  mole. 

It  sometimes  happens,  when  the  fetus  is  expelled  from  the  uterus, 
that  the  secundines  are  retained  by  adhesion,  and  continue  to  live 
and  be  developed.  It  is  precisely  in  such  cases  that  fleshy  moles  are 
formed.  Most  generally,  especially  in  the  early  months,  the  ovum  is 
expelled  entire ; it  has,  however,  been  known  to  be  expelled,  un- 
broken, at  the  fifth,  and  even  at  the  sixth  month ; but  in  the  greater 
number  of  cases,  its  size  will  not  permit  of  its  escape  entire  after  the 
second  month. 

[I  have  met  with  many  instances  in  which  the  embryo  has  been  retained 
for  several  months  in  the  womb,  after  the  cessation  of  its  life.  In  some 
other  cases  I have  found  the  placenta,  with  what  had  been  chorion  and  am- 
nion, but  greatly  changed  by  long  residence  in  the  uterus  after  the  death 
of  the  embryo,  which  had  taken  place  so  early  as  to  be  subject  to  macera- 
tion and  solution  in  the  waters.  Upon  searching  for  it  no  trace  of  it  has 
been  discoverable.  I should  not  look  upon  such,  as  a specimen  of  the  true 
mold,  but  as  a really  depraved  ovum.  That  these  ova,  (without  embryo,) 
continue  to  live,  and  to  a certain  extent  develop  themselves,  I have  no 
doubt,  since  upon  examining  them,  certain  portions  clearly  appear  to  have 
enjoyed  a sanguine  circulation,  small,  it  is  true,  but  yet  sufficiently  consi- 
derable, to  maintain  a low  vegetative  sort  of  life  for  several  consecutive 
months. 

I have  added  this  note  for  the  purpose  of  remarking  on  the  very  great 
difficulty  of  the  diagnosis,  and  the  doubtful  nature  of  the  therapeutical  indi- 
cations thereon  depending. 

I have  many  times  been  consulted  by  persons,  who,  having  had  symp- 
toms of  pregnancy,  had  unexpectedly  found  themselves  not  advancing  in  the 
uterine  development  pari  passu  with  the  lapse  of  time.  The  only  duty  in 
such  cases  is  to  collect  with  care  the  history  and  dates  of  the  mensual  periods, 
to  weigh  the  circumstances  that  led  to  the  opinion  that  conception  had  taken 
place,  and  then,  by  means  of  the  taxis  of  the  hypogastrium  and  the  vaginal 
examination,  to  learn  accurately  the  form  and  size  of  the  womb,  the  state  of 
the  cervix  and  os  uteri,  and  also  to  inquire  into  the  actual  and  past  condition 
of  the  mammary  glands  and  nipples. 

Should  the  form  and  size  of  the  uterus  lead  to  the  opinion  that  a fetus,  of 
an  age  conformable  to  the  rest  of  the  history  of  the  case,  is  still  contained  in 
the  organ,  there  need  be  very  little  hesitation  in  announcing  such  an  opinion, 
or  in  establishing  upon  it  a course  of  treatment.  Care  should  be  taken  to 


ABORTION. 


591 


compare  the  actual  development  of  the  womb  with  the  rate  at  which  a fibrous 
tumour  or  any  other  morbid  growth  might  have  proceeded;  and  thus  we 
shall  be  enabled  to  judge  between  the  doubtful  points  of  the  diagnosis.  The 
doubts  would  be  on  the  questions — 1st,  is  it  pregnancy,  with  arrest  of  de- 
velopment? 2d,  is  it  merely  engorgement  and  hypertrophy  of  the  womb? 
3d,  is  it  a tumour  within  the  organ  ? For  the  most  part,  by  making  a clear 
statement  of  the  various  circumstances  capable  of  presenting  phenomena  like 
those  of  the  case  under  consideration,  and  by  examining  the  grounds  for  de- 
ciding in  favour  of  either,  by  the  method  of  exclusion,  we  shall  rarely  be 
led  into  serious  mistakes. — M.] 

The  prognosis  of  abortion  regards  both  the  mother  and  the  child ; 
for  the  female  it  is  generally  more  dangerous  than  labour,  because 
the  latter  is  the  performance  of  a natural  function,  while  miscar- 
riage is  a disease.  Moreover,  its  prognosis  varies  according  to  the 
causes  which  have  produced  it  and  the  accidents  by  which  it  is 
accompanied.  The  least  dangerous  is  that  which  is  produced  by 
disease  of  the  ovum ; the  most  dangerous  that  which  has  been  occa- 
sioned by  a violent  exciting,  without  any  predisposing  cause.  Spon- 
taneous abortion  is  always  less  to  be  dreaded  than  forced  abortion, 
and  its  effects  are  the  less  unfavourable  in  proportion  as  it  occurs 
more  slowly.  We  remark,  also,  that  the  danger  is  less  in  pro- 
portion as  the  date  of  the  pregnancy  is  earlier,  as  the  neck  of  the 
womb  is  more  yielding,  and  as  the  accident  has  occurred  under  the 
influence  of  a well-marked  molimen.  Moreover,  the  abortion  is 
always  of  very  bad  augury  when  accompanied  by  convulsions, 
diarrhoea,  or  dysentery,  and  when  it  occurs  in  the  course  of  an  inflam- 
mation, of  a fever,  or  of  an  eruptive  disease.  The  prognosis  in  rela- 
tion to  the  foetus  is  still  more  unfavourable ; for  it  almost  always 
perishes  either  from  the  slowness  of  the  labour,  or  because  of  its  pre- 
mature expulsion ; we  ought  to  remark,  however,  that  there  are  to 
be  found  amongst  authors  several  examples  of  aborted  children 
which  have  survived,  although  the  conception  dated  only  from  four 
to  six  months.  It  is  generally  acknowledged  at  present  that  the  pro- 
bability of  survival  is  less  in  proportion  to  the  distance  from  full  term. 
It  is,  therefore,  without  any  good  reason  that  Hippocrates  has  said 
that  a child  at  seven  months  was  more  likely  to  live  than  one  at 
eight.  He  founded  this  opinion,  indeed,  mainly  upon  the  doctrine  of 
numbers.  As  to  the  particular  condition  of  the  female,  abortion  is 
most  dangerous  for  primipara,  because  the  genital  organs  are  less 
yielding  and  less  disposed  to  give  passage  to  the  product  of  concep- 
tion. 

The  treatment  of  abortion  presents  two  indications:  first,  to  prevent 
it  by  every  possible  means,  and,  secondly,  if  unable  to  prevent  it,  to 
hasten  its  termination,  and  to  remedy  the  accidents  which  accom- 
pany it.  To  fulfil  the  first  indication,  it  is  necessary  to  modify  the 
individual  and  the  predisposing,  and  to  remove  the  exciting  causes. 

If  the  female  is  nervous,  and  especially  if  her  uterine  system  is  in 
a state  of  unusual  spasm,  we  must  resort  to  the  use  of  warm  baths, 


592 


ABORTION. 


assisted  by  a demulcent  regimen.  When  she  is  of  plethoric  constitu- 
tion, we  may  with  advantage  bleed  several  times  in  the  course  of  the 
gestation,  especially  at  periods  corresponding  to  those  at  which  men- 
struation had  occurred. 

It  will  be  useful  also  to  relieve,  as  far  as  possible,  the  fatiguing 
coughs,  the  vomiting  and  constipation,  which  often  accompany  preg- 
nancy. We  should  recommend  strengthening  food,  repose,  slumber, 
and  always  moderate  exercise  for  delicate  persons : we  should  forbid 
all  violent  movements,  especially  those  of  the  arms,  leaping,  long 
walks,  the  lifting  of  weights,  and  riding  on  horseback,  or  in  a car- 
riage; they  should  be  advised  not  to  expose  themselves  to  intemperate 
weather,  to  avoid  tight  dressing,  not  to  use  indigestible  aliments, 
and  to  avoid,  as  much  as  possible,  all  the  vivid  emotions  and  affec- 
tions of  the  soul.  Should  there  exist  any  affection  of  the  uterus 
or  other  organ,  it  must  be  treated  by  a suitable  medication ; while 
we  should  have  recourse  to  the  employment  of  mercurial  prepara- 
tions, if  the  pregnancy  were  complicated  with  syphilitic  disease. 

Though  bleeding  is  generally  one  of  the  most  powerful  means  for 
preventing  abortion,  it  ought  not  to  be  indiscriminately  resorted  to  in 
all  cases ; wherefore  we  know  not  how  to  condemn  too  strongly  the 
habit  which  some  physicians  have  of  always  bleeding  in  the  course 
of  the  pregnancy,  without  first  distinguishing  the  circumstances 
which  call  for  its  employment,  which  is  as  hurtful,  in  some  cases,  as 
it  may  be  advantageous  in  many  others. 

When  haemorrhage  occurs,  the  patient  should  be  made  to  lie 
down  immediately  upon  a hard  and  fresh  bed,  and  be  directed  to 
maintain  absolute  rest.  We  should  make  use  of  cold  acidulated 
and  astringent  drinks,  especially  of  rhatany,  of  external  revellents, 
of  iced  applications,  injections  and  enemata ; and  if  there  are  symp- 
toms of  nervous  agitation  or  convulsions,  antispasmodic  and  anodyne 
preparations  ought  to  be  employed.  Moreover,  bleeding  is  one  of 
the  best  means  we  can  recur  to,  but  it  must  be  used  with  reserve 
and  precaution;  for,  as  it  is  often  powerless  against  abortion,  the 
accident  which  it  failed  to  prevent  might  be  ascribed  to  it.  In  gene- 
ral, so  long  as  there  is  any  hope  of  opposing  abortion,  we  should 
avoid  the  employment  of  foot-baths,  of  manuluvia,  and  of  full  baths. 
In  a contrary  condition,  their  use  might  be  advantageous. 

Should  the  haemorrhage  become  so  great  as  to  endanger  the  life  of 
the  patient,  recourse  must  be  had  to  the  tampon,  which  has  the 
advantage  of  arresting  the  haemorrhage  and  often  the  abortion,  or 
else,  by  the  accumulation  of  blood,  which  it  causes  in  the  uterus,  of 
determining  the  contractions  of  the  organ,  separating  the  placenta,  and 
assisting  in  the  expulsion  of  the  product  of  conception.  Under  these 
circumstances,  ergot  might  prove  useful,  but  it  should  be  employed 
with  care,  and  only  after  having  tried  all  the  other  means,  precau- 
tions the  more  necessary  as  it  almost  always  favours  the  expulsion 
of  the  ovum. 

When  the  means  we  have  just  pointed  out  fail  to  arrest  the  pains 
and  haemorrhage,  and  especially  when  the  cervix  begins  to  relax  and 
dilate,  abortion  is  inevitable.  The  physician,  under  these  circum- 


ABORTION. 


593 


stances,  has  nothing  to  do  but  assist  the  delivery,  and  aid  the 
woman  in  ridding  herself  of  the  foetus  and  its  appendages.  If  the 
patient  is  strong,  we  must  recur  to  venesection ; opium  must  be 
administered  internally,  when  the  pains  are  very  acute;  an  ointment 
of  belladonna  and  opium  may  be  applied  to  the  cervix  uteri,  if  it  be 
sensitive  and  firmly  contracted,  and  emollient  and  narcotic  injections 
might  also  be  used  under  like  circumstances.  Moreover,  should  the 
ovum  be  detained  a long  time  in  the  cervix,  it  would  be  advan- 
tageous to  introduce  the  finger,  and,  in  this  way,  assist  its  escape ; 
but  the  membranes  must  not  be  ruptured  until  the  orifice  of  the 
womb  is  fully  dilated,  and  the  foetus  properly  engaged.  When  pos- 
sible, the  placenta  ought  to  be  extracted,  by  pulling  upon  the  cord, 
taking  care,  however,  not  to  break  it.  We  might,  at  the  same  time, 
administer  ergot  and  use  frictions  over  the  hypogastrium  to  excite 
the  uterine  contractions.  If  it  could  be  done  without  using  too  much 
force  to  penetrate  the  cervix,  we  should  endeavour  to  separate 
the  placenta  with  the  aid  of  the  finger.  When  this  is  impracti- 
cable, its  separation  must  be  abandoned  to  the  vital  forces  of  the 
organism.  The  sequelae  of  the  escape  of  the  foetus  are  generally  the 
same  as  those  of  an  ordinary  labour ; that  is  to  say,  the  lochia  and 
the  milk-fever  require  the  same  attention. 

[I  believe  that  the  most  successful  mode  of  treating  persons  who  are  pre- 
disposed to  abortion,  before  the  period  of  quickening,  is  one  which  I have 
long  employed,  and  with  a most  satisfactory  success.  It  was  indicated  to 
me,  many  years  ago,  by  the  late  Dr.  Physick,  as  one  which  he  had  been 
much  accustomed  successfully  to  employ.  If  the  patient  has  had  repeated 
miscarriages,  I advise  her  to  use  an  anodyne  enema,  consisting  of  a wine- 
glassful  of  boiled  starch,  mixed  with  forty  drops  of  laudanum,  to  be  taken 
at  bedtime,  and  to  be  repeated  every  night,  until  quickening  takes  place. 
Perhaps  the  influence  of  the  laudanum  may  be  useful  in  suppressing  or 
lessening  the  act,  or  the  effect  of  the  vesicular  developments  in  the  ovaries 
or  at  least  it  may  deprive  the  uterus  of  an  abnormal  degree  of  sensibility, 
the  persistence  of  which  might  lead  it  to  the  early  contraction  of  its  walls 
and  the  consequent  expulsion  of  the  foetus. 

Dr.  Dewees  gives,  in  his  work  on  Midwifery,  p.  404,  2d  edition,  the 


Fig.  48. 


adjoining  drawing  of  what  has  been  here  long  denominated  Dewees’  pla- 
centa-hook, and  which  is  sold  by  the  surgeons’  instrument-makers  of  this 
city.  The  figure  is  one-third  less  than  the  usual  size  of  the  instrument.  Dr. 
D.  gives  the  following  directions  as  to  the  use  of  it: 

“ The  forefinger  of  the  left  hand  is  placed  within,  or  at  the  edge  of  the  os 
tincae  ; with  the  right  we  conduct  the  hooked  extremity  along  this  finger 
38 


594 


ABORTION. 


until  it  is  within  the  uterus;  it  is  gently  carried  up  to  the  fundus,  and  then 
slowly  drawn  downwards,  which  makes  its  curved  point  fix  in  the  placenta  : 
when  thus  engaged,  it  is  gradually  withdrawn,  and  the  placenta  with  it.” 
— ( System  of  Mid.,  p.  404.) 

The  distinguished  writer  speaks  of  the  success  he  has  met  with  in  using 
this  instrument;  but  I cannot  say  that,  in  the  various  occasions  of  trying 
the  hook,  I have  been  so  fortunate.  In  fact,  I have  learned  to  believe  that 
where  the  cervix  and  os  uteri  are  dilated,  or  dilatable,  the  ovum,  whether 
entire  or  broken,  in  abortions,  comes  readily  to  the  os  uteri,  from  whence  it 
may  be  taken  with  the  point  of  the  forefinger;  and  that,  where  the  passage 
is  not  dilated,  all  attempts  to  pull  it  away  by  force  are  both  unnecessary  and 
dangerous. 

In  abortions,  there  is  no  hazard  in  the  use  of  the  tampon,  where  it  is  re- 
solved that  all  hope  of  saving  the  pregnancy  is  to  be  abandoned.  Perhaps 
some  reflection  and  hesitation  might  be  proper,  as  to  the  tampon,  at  five  or 
five  and  a half  months  of  gestation  ; but,  up  to  the  period  of  four  or  four  and 
a half  months,  I look  upon  the  tampon  as  the  means  of  security  in  all  haemor- 
rhages from  abortion ; and  I very  confidently  expect,  in  general,  that  upon  the 
withdrawal  of  the  tampon,  after  its  purposes  have  been 
subserved,  I shall  find  the  ovum  in  the  cervix  and  os 
uteri,  whence  I can  take  it  with  the  finger.  Dr. 
Dewees*  placenta-hook  would  be  very  convenient  un- 
der such  circumstances,  no  doubt ; yet,  where  the 
dilatation  of  the  passages  is  incomplete,  the  hook 
would  be  very  apt  to  tear  out  of  the  soft  and  often 
semi-putrid  mass  of  the  placenta. 

My  friend,  Dr.  Henry  Bond,  a highly  esteemed 
practitioner  of  our  city,  has  lately  published,  in  the 
Jlmer.  Jour,  of  the  Med.  Sciences  for  April,  1844, 
an  article  on  the  “Extraction  of  Retained  Placenta  in 
Abortion.” 

Dr.  Bond,  in  the  very  sensible  paper  in  question, 
examines  the  pretensions  of  the  various  instruments 
in  use  for  the  purpose,  and,  after  weighing  their  se- 
veral merits  and  defects,  he  proposes  a new  instru- 
ment, which  he  calls  the  placental  forceps , of  which 
the  adjoining  cut  gives  a good  idea.  “The  instru- 
ment is  ten  inches  long,  curved  laterally  on  a radius 
of  about  twelve  inches,  and  the  blades  are  about  an 
inch  and  a half  longer  than  the  handles.  The  blades 
terminate  in  an  oval  expansion,  nearly  half  an  inch 
wide,”  &c. 

I have  had,  hitherto,  no  occasion  to  make  use  ol 


ABORTION. 


595 


Dr.  B.’s  placental  forceps;  but  I feel  assured  that  it  is  the  most  convenient, 
safe  and  useful  implement  that  has  as  yet  been  proposed  for  the  purpose. 

A good  many  cases  of  abortion,  in  the  early  stage,  as  from  the  sixth 
week  to  the  tenth,  have  fallen  under  my  notice,  in  which  the  uterus  was 
unable  to  expel  the  remains  of  the  ovum,  and  in  which  I could  not  extract 
it.  The  patient,  in  such  instances,  has  always  recovered,  without  the 
ovum  having  been  visibly  discharged,  except  with  here  and  there  a shred 
or  a lump  of  macerated  organic  matter.  In  these  samples  there  is  a nearly 
constant  excretion  of  dark  grumes  and  offensive  sanies,  sometimes  bloody, 
and  often  of  a rust  colour.  I presume  that  the  remains  of  the  ovum  un- 
dergo a slow  maceration  and  decomposition,  so  as  to  escape  imperceptibly. 
I consider  it  better  to  leave  the  ovum,  in  such  cases,  to  the  care  of  nature, 
than  to  reiterate  attempts  to  extract  it  by  force;  there  is  as  great  danger 
of  exciting  inflammation  of  the  womb,  by  such  attempts,  as  by  leaving  the 
placenta  to  the  process  of  gradual  maceration  and  discharge.  I am  not  dis- 
posed to  deny  that  the  presence  of  a putrefying  substance,  even  of  a small 
size,  in  the  womb,  is  capable  of  developing  violent  inflammation  and  fever; 
but  it  has  not  happened  so  with  me;  and  I have  given  advice  to  some  of 
my  younger  medical  friends,  when  consulted  on  such  occasions,  to  abandon 
the  attempt ; it  being  always  understood  that  reasonable  efforts  ought  to  be 
made  to  get  the  placenta  away. — M.] 

OF  NAUSEA  AND  VOMITING. 

Diseases  of  pregnancy  depending  upon  the  sympathetic  influence  of  the  womb  upon 
the  different  functions  of  the  organism. 

Nausea  and  vomiting  are  phenomena  which  so  frequently  accom- 
pany pregnancy,  that  their  presence  is  ordinarily  its  first  symptom, 
and  is  sufficient  to  make  us  infer  its  existence. 

Nausea,  which  may  be  regarded  as  the  first  stage  of  the  vomiting, 
sometimes  exists  alone,  and  is  more  distressing,  even,  when  it  persists, 
than  the  latter.  Some  writers  have  supposed  that  these  accidents  of 
pregnancy  were  owing  to  the  pressure  of  the  womb  upon  the  sto- 
mach, and  of  the  thrusting  of  that  viscus  up  into  the  oesophagus.  This 
opinion  is  inadmissible,  especially  in  the  early  months,  for  the  nausea 
and  vomiting  often  appear  immediately  after  fecundation,  and  gene- 
rally become  less  frequent  in  proportion  as  the  womb  increases  in 
size,  and  ascends  in  the  abdomen.  For  the  same  causes,  the  early 
signs  of  pregnancy  can  with  no  better  reason  be  ascribed  to  plethora, 
as  supposed  by  Boerhaave  and  Smellie.  They  are  evidently,  there- 
fore, due  to  the  sympathetic  action  of  the  gestative  organ  upon  the 
stomach.  Besides,  this  influence  is  further  demonstrated  by  the 
derangement  of  the  digestive  functions,  where  the  uterus  is  the  seat 
of  any  disease  whatever. 

The  nausea  and  vomiting  generally  cease  after  the  third  or  fourth 
month.  In  some  cases,  however,  they  last  until  the  onset  of 
labour,  while  in  others  they  cease  at  first  at  the  ordinary  time,  but 
reappear  in  the  later  months,  which  seems  to  depend  upon  the  pres- 
sure which  the  womb  then  exerts  upon  the  stomach. 


596 


NAUSEA  AND  VOMITING. 


The  sympathetic  phenomena  also  vary  exceedingly  as  to  their  fre- 
quency, and  the  periods  of  the  day  at  which  they  make  their  appear- 
ance. Most  commonly,  the  vomiting  occurs  in  the  morning.,  and 
then  consists  merely  of  a viscid  fluid.  It  often  occurs,  also,  in  the 
course  of  the  day,  and  especially  just  after  meals.  The  solid  and 
liquid  food  are  both  rejected ; and  there  are  some  women  who 
scarcely  retain  a few  spoonfuls  of  sweetened-water,  or  of  broth  or 
coffee,  while  in  others,  again,  the  vomiting  is  calmed  by  the  ingestion 
of  food  into  the  stomach. 

In  some  cases,  where  the  vomiting  is  very  frequent  and  painful, 
it  may  bring  on  abortion,  especially  where  a predisposition  to  it 
exists.  Though  not  always  followed  by  unfortunate  consequences, 
the  violent  succussions  which  it  occasions,  and  the  diminution  in  the 
amount  of  nourishment  produced  by  it,  necessarily  cause  emaciation 
and  debility  in  the  patient. 

[I  have  met  with  but  one  case  of  abortion  that  could  be  attributed  to 
the  vomiting,  whence  I conclude  that  nausea  and  vomiting  are  rarely  causes 
of  abortion. — M-3 

The  sickness  appears  to  be  connected  sometimes  with  a gastric 
derangement,  characterized  by  a bitter  taste  in  the  mouth,  by  a yel- 
low colour  of  the  tongue,  and  by  bilious  vomiting.  It  is  very  im- 
portant to  distinguish  cases  of  this  kind  from  those  which  depend 
upon  a sympathetic  influence  of  the  uterus  upon  the  stomach.  The 
diagnosis  is  generally  easy  when  no  doubt  exists  as  to  the  fact  of 
pregnancy. 

Though  the  vomiting  is  exceedingly  distressing  in  some  women,  the 
prognosis  is  not  generally  unfavourable.  We  have  often  known 
pregnancy  to  pass  happily  through  all  its  stages,  though  accompa- 
nied, during  its  whole  course,  by  vomiting,  giving  rise  to  very  violent 
general  spasms  and  excessive  pain  in  the  epigastric  region. 

The  treatment  of  vomiting  varies  according  to  its  violence  and 
frequency,  and  the  nature  of  the  causes  whose  action  produces  it. 

When  sympathetic,  we  generally  recommend  a mild  regimen,  and 
especially  one  composed  of  the  articles  most  easily  digested  by  the 
patient.  In  many  women,  the  most  indigestible,  and  least  suitable 
in  appearance,  are  the  only  ones  which  the  stomach  will  bear : it  is 
better,  when  such  is  the  case,  for  them  to  take  improper  food  than 
none  at  all. 

Some  women  likewise  find  it  useful  to  take,  after  meals,  a small 
glass  of  Madeira  or  Frontignac  wine,  or  of  pure  brandy  even,  or  of 
cherry-brandy,  or  of  rum  alone  or  mixed  with  water.  Good  effects 
have  been  obtained  from  Riverius’s  draught,  also  from  Seltzer- 
water,  from  Columbo  root,  from  a few  drops  of  laudanum,  or  ether, 
from  mint-water,  from  syrup  of  poppy-heads,  from  two  or  three  ipe- 
cacuanha troches,  and,  lastly,  from  extract  of  cinchona  or  sulphate  of 
quinine,  especially  if  the  vomiting  and  epigastric  pain  are  accompa- 
nied by  slight  febrile  movement,  and  seem  to  assume  a periodical 
character.  Some  practitioners  have  also  recommended,  when  the 
vomiting  is  obstinate,  the  application  of  a large  cup  over  the  region 


PTYALISM. 


597 


of  the  stomach,  after  each  meal.  The  use  of  an  opium  plaster,  or  of 
a poultice,  sprinkled  with  Sydenham’s  laudanum,  has  likewise  been 
tried.  Finally,  in  two  cases  of  purely  nervous  vomiting,  M.  Joubert, 
of  Lyons,  cured  the  patients  immediately,  by  the  application  of  a 
mustard  plaster  over  the  last  dorsal  vertebrae. 

We  have  obtained  the  same  result,  on  several  occasions,  by  means 
of  frictions  upon  the  epigastric  region,  with  Autenrieth’s  antimonial 
ointment. 

If  the  vomiting  coincides  with  a saburral  condition  and  with  gastric 
derangement,  we  resort  to  the  employment  of  some  mild  purgatives, 
as,  for  example,  a Seidlitz  powder,  manna,  castor  oil,  cassia,  tama- 
rinds, rhubarb,  infused  in  the  proportion  of  four  grains,  and  to 
emetics,  even.  We  combine,  with  these  means,  a properly  regulated 
regimen,  or  a rigid  diet;  the  use  of  acidulated  and  gummy  drinks, 
lemonade,  gooseberry  syrup,  baths,  and  emollient  enemata  and  cata- 
plasms. 

If  the  sickness  coincide  with  a plethoric  condition,  especially  if 
the  woman  have  been  abundantly  regulated  before  pregnancy,  we 
must  resort  to  bleeding  from  the  arm  and  to  the  application  of 
leeches  to  the  epigastrium,  especially  when  that  region  is  painful  and 
exhibits  some  signs  of  inflammation.  We  might,  at  the  same  time, 
make  use  of  diluents,  and  subsequently  of  antispasmodics.  It  is 
proper  for  us  to  remark,  moreover,  that,  in  some  women,  pregnancy 
is  unaccompanied  by  either  nausea  or  vomiting,  and  that  none  of  the 
sympathetic  phenomena  we  have  yet  to  notice,  occur  in  them. 

OF  PTYALISM. 

Ptyalism,  which  constitutes  one  of  the  first  signs  of  pregnancy  in 
many  women,  is  characterized  by  an  excessive  secretion  from  the 
salivary  glands,  far  more  inconvenient  than  dangerous.  This  exu- 
berance of  salivation  generally  appears  soon  after  conception,  and 
ceases  commonly  towards  the  fourth  month;  but, in  some  cases,  lasts 
until  the  end  of  gestation,  or  does  not  even  make  its  appearance 
until  a short  time  before  labour. 

The  ptyalism,  which  is,  in  some  sort,  a precursory  symptom 
merely,  and  a primary  degree  of  the  nausea  and  vomiting,  seems  to 
depend,  like  them,  upon  the  increased  vitality  of  the  uterus  during 
pregnancy,  and  upon  the  sympathetic  relations  existing  between  the 
gestative  organ  and  the  salivary  glands. 

When  the  salivation  is  slight,  it  is  to  be  left  to  nature;  but  though 
it  is  dangerous  to  arrest  the  secretion  suddenly,  especially  when  the 
quantity  is  very  great,  it  is  wise  to  moderate  it  should  it  produce 
debility  of  the  patient  and  derangements  of  the  digestive  functions. 
To  attain  this  end,  all  that  is  commonly  necessary  is  to  keep  the 
bowels  soluble  by  diluent  and  laxative  drinks,  by  fluid  magnesia, 
by  enemata  and  by  a substantial  and  digestible  regimen. 

We  may  recommend,  also,  the  use  of  sulphur  troches,  of  opiate  gar- 
gles, of  draughts  with  balm,  mint,  and  canella  water,  taken  by  spoon- 
fuls throughout  the  day.  Should  these  means  fail,  we  may  employ 
bleeding,  or  make  applications  of  leeches  to  the  angle  of  the  jaw. 


598 


TOOTHACHE. 


[I  recently  had  a lady  under  my  charge,  who  had  ptvalism  throughout 
the  whole  pregnancy;  for  many  months  she  discharged  at  least  a pint  of 
saliva  daily,  and  was  not  very  sensibly  weakened  by  the  discharge. — M.] 

OF  ODONTALGIA. 

The  odontalgia  of  pregnant  women  may  depend  on  different  causes, 
which  require  particular  plans  of  treatment. 

The  affection  is  generally  a dental  neuralgia,  which  commences 
with  more  or  less  violent  pains,  confined  generally  to  the  lower  jaw. 
When  this  is  the  case,  all  the  teeth  of  one  or  both  sides  of  the  jaw  are 
painful,  while,  if  the  odontalgia  depends  upon  caries,  the  pain  is  con- 
fined to  the  diseased  tooth.  The  aching  is  sometimes  so  violent,  that 
it  extends  to  the  whole  face  and  in  the  course  of  the  branches  of  the 
seventh  pair  of  nerves.  It  is  proper  to  remark,  also,  that  there  is 
neither  swelling,  heat,  throbbing,  nor  any  trace  of  change  of  tissue  in 
toothache  of  this  kind,  as  happens  when  the  dental  pain  depends  upon 
an  inflammatory  condition. 

To  relieve  the  neuralgic  affection,  Meglin’s  pills  are  used,  in  doses 
of  four  or  six  pills  daily;  the  sub-carbonate  of  iron  combined  with 
rhubarb ; emollient  and  anodyne  lotions,  and,  also,  cataplasms  of 
the  same  kind.  To  these  means  are  added  the  application  of  a 
plaster  of  extract  of  opium  over  the  course  of  the  diseased  nerve,  and 
that  of  a blister  behind  the  ear  on  the  affected  side ; in  some  cases, 
the  application  of  four  or  five  leeches  to  the  gums  cannot  but  be 
advantageous,  and  assist  the  action  of  the  other  remedies.  When 
the  neuralgic  pains  are  intermittent,  which  is  often  the  case,  sulphate 
of  quinine  united  with  opium  is  prescribed ; lastly,  should  all  these 
means  fail,  we  may  make  trial  of  the  following,  recommended  by 
Guide  meau  : 

Take  the  whites  of  two  eggs,  common  pepper  in  powder  gii,  beat  strongly  together 
and  spread  the  preparation  on  tow,  which  is  to  be  applied  to  the  cheek  of  the  affected 
side. 

If  the  odontalgia  depend  upon  an  inflammatory  state  of  the  gums, 
the  patient  experiences  heat  and  throbbing  at  the  diseased  point;  an 
abscess  sometimes  forms  in  the  alveolus,  which  suppurates  around 
the  tooth  and  gives  rise  to  swelling  and  pain  that  often  extend  to 
the  eye  and  even  the  ear  of  the  same  side.  The  pain,  which  is  kept 
up  in  the  case  by  plethora,  generally  yields  to  the  employment  of 
bleeding  from  the  arm  and  to  the  application  of  leeches  to  the  gums. 
It  is  advantageous  to  add  to  these  means  the  use  of  foot-baths,  of 
enemata,  of  diluent  drinks,  rigid  diet,  and  lastly,  attention  to  keeping 
the  head  warm,  and  the  employment  of  emollient  vapours  directed 
to  the  mouth. 

When  the  toothache  depends  upon  caries  of  a tooth,  it  must  be 
promptly  extracted,  unless  the  female  is  so  irritable  as  to  make  us 
fear  abortion;  then  we  should  combine  with  the  employment  of  in- 
ternal and  external  antispasmodics  the  application  of  a blister  behind 
the  ear  of  the  affected  side.  If  the  dental  pains  be  caused  by  gas- 
tric derangement,  the  treatment  ought  to  consist  in  the  use  of  laxa- 
tives, and  amongst  others  of  fluid  magnesia. 


LOSS  OF  APPETITE. 


599 


OF  ANOREXIA. 

Anorexia , or  the  disgust  inspired  by  food,  is  a phenomenon  often 
observed  in  pregnant  women,  especially  in  the  early  months.  In 
some  cases  it  exists  in  regard  to  certain  kinds  of  food  only,  but  gene- 
rally includes  all  descriptions.  Like  the  affections  already  described., 
the  anorexia  may  be  caused  either  by  a nervous  condition  of  the 
stomach,  by  gastric  derangement,  or  by  a state  of  plethora  which  is 
met  with  principally  in  women  of  strong  and  sanguine  constitution. 

When  of  a nervous  character,  it  may  be  recognized  by  the  absence 
of  the  signs  which  characterize  the  other  varieties ; it  is  to  be  treated 
by  antispasmodics  and  sedatives ; among  others,  emollient  fomenta- 
tions to  the  epigastric  region,  general  baths,  enemata,  weak  infusions 
of  linden-flowers,  of  orange-flowers,  of  chamomile,  and  of  valerian, 
sweetened  with  ether  syrup,  and  with  the  addition  of  a few  drops 
of  Sydenham’s  laudanum. 

We  may  join  to  these  means  the  use  of  Seltzer- water  with  or 
without  lemon  juice,  and  sometimes  that  of  the  ferruginous  prepa- 
rations, among  others,  the  subcarbonate  of  iron. 

If  anorexia  occurs  in  a female  in  whom  a hard  pulse,  strong  throb- 
bings  of  the  heart,  swelling  of  the  veins,  general  numbness,  and 
redness  and  puffiness  of  the  face,  show  that  there  is  evident  plethora., 
rigid  diet,  bleeding  at  the  arm,  and  even  leeches  to  the  epigastrium 
are  indicated,  especially  during  the  fourth  and  fifth  months  of  gesta- 
tion. Finally,  when  the  loss  of  appetite  depends  upon  gastric  de- 
rangement, with  bitter  and  pasty  mouth  and  yellowish  or  whitish 
fur  upon  the  tongue,  it  becomes  proper  to  prescribe  diluent  drinks., 
and  lemonade ; moreover,  if  there  is  no  pain  at  the  epigastrium, 
the  saburral  state  of  the  stomach  may  be  more  directly  treated  by 
means  of  ten  or  twelve  grains  of  ipecacuanha  or  by  a mild  saline 
purge,  in  case  no  intestinal  disorder  be  present.  Anorexia  depend- 
ing upon  debility  of  the  stomach  generally  yields  to  the  employment 
of  tonics,  bitters  and  ferruginous  waters. 

We  may  add  that  it  is  generally  unnecessary  to  do  much  for  ano- 
rexia, as  it  commonly  ceases  after  the  fourth  month  of  pregnancy ; 
when  it  lasts  longer,  it  becomes  in  some  cases  a means  employed  by 
nature  to  prevent  plethora.  Besides,  the  want  of  appetite  seems  to 
have  but  little  influence  in  some  women,  who  bear  well-formed  chil- 
dren, and  retain  their  embonpoint  and  freshness  through  the  whole 
of  the  gestation. 


OF  BOULIMIA. 

Though  we  generally  find  that  pregnant  women  lose  their  appetite 
and  take  complete  disgust  to  all  kinds  of  food,  there  are  some  also  who, 
during  pregnancy,  have  an  extraordinary  appetite.  This  species  of 
boulimia,  which  often  gives  rise  to  gastritis,  to  vomiting  and  to  diffi- 
cult digestion,  and  which  becomes  sometimes  a necessity  so  impe- 
rious as  to  amount  to  delirium,  often  yields  to  the  employment  of 
some  nourishing  liquids,  such  as  broths,  rice-milk,  chocolate,  or  else 


600 


BOULIMIA,  DYSPEPSIA,  THIRST. 


to  the  use  of  other  substances  containing  a large  amount  of  nutriment 
in  a small  space,  among  others  the  animal  jellies,  feculent  substances 
or  eggs  in  the  shell.  We  may  likewise  cheat  the  hunger  by  means 
of  some  morsels  of  chocolate  or  sugar ; and  we  may  modify  the  ab- 
normal nervous  state  of  the  stomach  with  the  gaseous  and  ferrugi- 
nous waters  and  with  some  of  Darcet’s  troches. 

OF  DYSPEPSIA  AND  POLYDIPSIA. 

Though  the  difficulty  of  digestion  called  dyspepsia  is  in  some  cases 
symptomatic  of  an  affection  of  the  stomach,  it  is  ordinarily  idiopathic 
in  pregnant  women,  and  constitutes  a neurosis  of  the  digestive  appa- 
ratus. The  patients  experience,  after  eating,  a sensation  of  fulness 
and  distension  at  the  epigastrium,  ordinarily  accompanied  by  general 
uneasiness,  by  more  or  less  thirst,  and  sometimes  by  nausea,  vomit- 
ing and  cardialgia. 

The  prognosis  of  the  affection  is  generally  good,  for  it  commonly 
begins  with  pregnancy  and  disappears  after  the  fourth  or  fifth  month. 
Sometimes,  however,  it  does  not  appear  until  the  latter  months,  but 
ceases  in  that  case  with  the  gestation.  In  all  cases  it  seems  to  exert 
but  little  influence  upon  the  development  and  health  of  the  child. 

The  treatment  of  the  disorder  is  very  simple : it  consists  in  the 
employment  of  the  bitter  medicines,  such  as  the  infusions  of  gentian, 
of  the  lesser  centaury,  of  absinthium,  of  mint,  rhubarb,  and  especially 
of  chamomile.  The  action  of  these  remedies  is  assisted  by  the  use 
of  the  ferruginous  and  gaseous  waters,  mixed  with  a little  wine ; and 
by  wholesome  food  composed  of  articles  of  easy  digestion,  such  as 
meat  soups,  white  meats  and  very  ripe  fruits.  Finally,  the  digestive 
powers  of  the  stomach  are  sustained  by  Vichy  troches,  by  some 
alcoholic  liquor,  among  others,  Bordeaux  anisette,  cherry  brandy, 
and  Garus’s  elixir,  or  by  the  use  of  coffee  or  tea.  It  is  proper  to 
remark  that  in  some  cases,  we  may  resort  with  advantage  to  the 
employment  of  antispasmodics,  given  conjointly  with  tonics.  If  the 
dyspepsia  be  brought  on  by  polydipsia , or  excessive  ingestion  of 
liquid's  into  the  stomach,  it  may  be  remedied  by  the  use  of  baths,  of 
a few  grains  of  nitre  in  lemonade,  taken  frequently  and  in  small 
quantity  at  a time,  or  else  by  means  of  ether  and  water,  according  to 
the  recommendation  of  Baron  Larrey. 

OF  CAPRICIOUS  APPETITE  (PICA,  MALACIA.) 

The  longings  of  pregnant  women  are  as  variable  as  they  are 
numerous.  Some  are  tormented  with  a desire  not  only  to  eat  sub- 
stances which  are  not  included  in  the  list  of  aliments,  but  which  are 
of  the  most  disgusting  character  even.  This  constitutes  the  pica, 
while  by  the  term  malacia  is  meant  the  exclusive  desire  for  a sub- 
stance belonging  to  those  used  as  food.  We  have  seen  women  who, 
though  completely  fastidious,  were  affected  with  one  of  these  depra- 
vations of  taste,  and  who  longed  to  swallow  chalk,  plaster,  cinders, 
charcoal,  green  fruits,  vinegar,  strong  liquors,  suet,  caterpillars,  flies, 
opiders,  and  even  excrement.  Anomalies  of  this  kind,  which  are 


PICA,  MALACIA,  ETC. 


601 


also  observed  in  hysterical  and  chlorotic  women,  and  in  those  who 
have  suppressed  or  irregular  menstruation,  are  quite  frequent  in  the 
early  months  of  pregnancy,  and  commonly  cure  themselves.  In 
general,  it  has  been  remarked  that,  whatever  be  the  substances  that 
are  introduced  into  the  stomach  in  this  condition,  no  evil  has  resulted 
to  the  female  from  it,  which  to  a certain  extent  permits  us  to  suppose 
that  it  is  nature  which  inclines  her  to  introduce  into  her  economy 
materials  necessary  to  her  new  physiological  condition. 

Without  believing  in  the  marvellous  effects  of  the  spots  {naevi  ab 
imaginatione)  and  deformities  of  the  foetus  occasioned  by  the  caprices 
of  pregnant  women,  we  are  of  opinion  that  there  is  no  reason  for 
denying  them  any  thing,  or  for  refusing  to  yield  to  a well-marked 
appetite,  unless,  indeed,  the  substances  longed  for  are  evidently  hurt- 
ful. It  is  readily  conceivable  that  a disappointed  wish  and  an  un- 
gratified longing  carried  to  a certain  extent  may  produce  dangerous 
consequences  to  the  mother,  and  thus  interfere  with  the  formation 
and  development  of  the  embryo. 

The  treatment  of  capricious  appetite  is  nearly  the  same  as  that  of 
the  other  neuroses  of  the  stomach  ; that  is  to  say,  we  prescribe  eme- 
tics and  purgatives,  where  the  affection  coincides  with  a gastric  de- 
rangement; bleeding,  if  there  is  plethora;  and,  finally,  antispasmodics, 
syrup  of  ether,  and  laudanum,  as  well  as  the  bitter  infusions  of  the 
lesser  centaury,  of  balm,  and  of  rhubarb,  and  the  martial  prepara- 
tions, should  the  first  means  not  suffice.  We  shall  add  that  the  dis- 
ease is  often  left  to  itself,  because  it  almost  always  yields  after  the 
first  months  of  pregnancy,  and  generally  bears  upon  substances, 
that  do  not  prevent  the  female  from  taking  other  aliment,  and  enjoy- 
ing comfortable  health. 

OF  PYROSIS,  DYSPHAGIA  AND  HEARTBURN. 

Pyrosis  is  an  affection  which  consists  in  a sense  of  burning  pain 
in  the  stomach,  with  eructation  of  an  acrid  fluid  that  produces  a very 
painful  feeling  of  heat  throughout  the  oesophagus,  and  even  in  the 
mouth. 

The  causes  of  the  affection  are  almost  always  inappreciable ; 
nevertheless,  they  commonly  occur  in  persons  who  make  use  of  food 
that  is  heavy  and  difficult  of  digestion,  as  fried  dishes,  salt  meats, 
old  cheese,  and  alcoholic  liquors.  In  pregnant  women,  it  generally 
occurs  in  the  first  months  of  pregnancy,  without  our  being  able  to 
ascribe  it  to  any  other  cause  than  the  sympathetic  influence  of  the 
uterus  upon  the  stomach. 

Idiopathic  pyrosis,  or  even  that  which  is  symptomatic  of  pregnancy, 
is  generally  a disease  of  which  the  prognosis  is  not  unfavourable;  for 
when  it  occurs  in  the  early  periods  of  conception,  it  ceases  towards 
the  fourth  month,  or  else,  when  it  comes  on  in  the  latter  period  of 
pregnancy,  it  terminates  at  the  period  of  the  delivery. 

The  treatment  of  a pyrosis  in  pregnant  females  generally  consists 
in  the  administration  of  magnesia,  and  of  lime-water  combined  with 
antispasmodics  and  anodynes,  such  as  extract  of  valerian,  syrup  of 


602 


PYROSIS,  DYSPHAGIA,  GASTRALGIA. 


ether,  and  especially  opium,  given  in  the  paroxysms.  To  these 
means  are  added  a milk  and  vegetable  diet,  and  demulcent  and  muci- 
laginous drinks.  Sometimes  the  employment  of  the  martial  prepara- 
tions, among  others,  the  subcarbonate  of  iron  and  the  ferruginous 
waters,  are  found  to  answer  well.  Good  results  have  also  been 
obtained  from  the  internal  use  of  nux  vomica  in  powder,  in  the  dose 
of  from  one  to  three  grains,  twice  a day.  Finally,  when  the  disease 
attacks  periodically,  the  latter  are  advantageously  treated  by  means 
of  sulphate  of  quinine  combined  with  a little  opium. 

Dysphagia,  or  difficulty  of  swallowing,  characterized  by  spasmodic 
contraction  of  the  oesophagus  by  the  sensation  of  a body  arrested  in 
the  throat,  is  a phenomenon  often  produced  by  the  sympathetic  in- 
fluence of  the  uterus  in  pregnancy.  Though  the  nervous  symptom, 
under  these  circumstances,  is  commonly  transient  and  unimportant, 
it  nevertheless  sometimes  requires  a treatment  consisting  in  the 
employment  of  antispasmodics,  and  frictions  of  the  lateral  and  ante- 
rior portions  of  the  neck,  with  balsam  of  Fioraventi  and  ban  me 
tranquille.  We  have  found  the  following  ointment  to  answer  a 
very  good  purpose  in  our  hands: 

R. — Extract  Belladon.,  grs.  xl vii. 

“ Stramon.,  grs.  xv. 

Cerati,  3i. 

Olei  Limon.,  gtt.  xii. 

To  be  applied  by  friction,  to  the  neck,  morning  and  evening. 

We  have  cured  the  dysphagia  also  by  giving  to  the  patient  a little 
cherry  brandy,  rum,  or  Bordeaux  anisette  mixed  with  water. 

Heartburn  is  a very  common  indisposition  in  pregnant  women, 
especially  in  blondes  and  those  of  a lymphatic  temperament.  It  is  a 
frequent  symptom  of  dyspepsia,  but,  in  the  greater  number  of  cases, 
results  from  an  aberration  of  taste,  since  the  patients  find  all  their 
food  to  be  acid,  or  else,  which  is  still  more  common,  it  is  produced 
by  acids  actually  existing  in  the  stomach. 

The  acid  sensation,  which  is  more  inconvenient  than  dangerous, 
and  which  generally  ceases  towards  the  fourth  month,  commonly 
coincides  with  paleness  of  the  face,  heat  in  the  region  of  the  stomach 
and  along  the  oesophagus,  and  with  risings  and  even  vomiting  or 
eructations  of  acrid  matters. 

For  the  treatment  of  this  affection  are  recommended  tonics,  espe- 
cially cinchona,  gentian  and  rhubarb.  We  prescribe  also,  in  order 
directly  to  neutralize  the  acids  of  the  stomach,  alkaline  substances, 
magnesia,  the  subcarbonates  of  soda  and  potassa,  Darcet’s  troches, 
and  especially  a spoonful  or  two  of  lime-water  in  half  a cup  of  milk, 
taken  two  or  three  times  a day.  To  these  means  should  be  added 
a tonic  regimen,  roast  meats,  nourishing  soups,  moderate  exercise, 
and  residence  in  the  country,  or,  at  least,  in  a dry  and  temperate  air. 

OF  GASTRALGIA. 

The  gastralgia,  to  which  pregnant  women  are  subject,  is  charac- 
terized, like  other  forms  of  the  same  disorder,  by  acute  pain,  and  by 


GASTRALGIA. 


603 


a,  feeling  of  dragging  and  laceration  at  the  epigastrium.  This  kind 
of  gastralgia,  vulgarly  known  by  the  name  of  nervous  colic  or 
cramp  of  the  stomach , may,  in  some  cases,  suddenly  disappear,  and 
not  return.  When  momentary  merely,  the  functions  undergo  no 
sensible  change;  but  where  it  continues  with  full  violence,  the  patient, 
more  and  more  oppressed,  is  obliged  to  sit  down,  to  keep  the  body 
inclined,  and  bend  herself  forward  while  pressing  upon  the  epigas- 
trium. We  can  distinguish  nervous  pains  of  the  stomach  from  those 
produced  by  inflammation  of  that  organ,  by  observing,  that  in  gas- 
tralgia there  is  always  absence  of  fever ; that  the  tongue  presents  its 
natural  colour,  and  that  the  pains,  which  have  intervals  of  paroxysm 
and  repose,  are  not  aggravated,  but  are  even  relieved,  sometimes,  by 
pressure.  The  contrary  occurs  in  gastritis,  which  occasions  less 
severe,  but  always  more  constant  pain. 

We  have  seen  attacks  of  gastralgia  occur  in  some  women,  as  soon 
as  the  stomach  became  empty,  while  the  pains  ceased  immediately 
upon  taking  some  solid  or  liquid  substance.  In  others,  again,  they 
recur  immediately  after  eating,  or  after  the  slightest  impression  of 
cold  upon  the  arms,  shoulders,  and  especially  the  feet. 

The  treatment  of  the  disorder,  which  differs  but  little  from  that  of 
the  preceding,  presents  two  fundamental  indications.  The  first  con- 
sists in  acting  during  the  paroxysm,  so  as  to  lessen  its  severity  and 
duration,  and  the  other  in  preventing,  as  far  as  possible,  the  return. 

During  the  paroxysm,  a large  flaxseed  poultice  should  be  applied 
to  the  epigastrium,  as  hot  as  the  patient  can  bear  it.  It  is  well  to 
sprinkle  the  poultice  with  a little  mustard;  but,  when  this  is  done,  it 
must  be  kept  applied  a shorter  time.  It  is  good  also  to  prescribe 
several  tablespoonfuls  of  some  antispasmodic  mixture.  We  have 
always  found  the  following  to  answer  extremely  well: 

R. — Of  orange  and  linden-flower  water,  each  two  ounces;  of  syrup  of  ether  and 
of  valerian,  each  an  ounce;  of  syrup  of  poppy-heads,  half  an  ounce.  Of  this,  a tea- 
spoonful is  to  be  given  every  quarter  of  an  hour. 

To  prevent  the  return  of  the  paroxysm,  we  should  prescribe  the  use 
of  baths,  enemata,  diluent  drinks,  and  warm  applications  to  the  epi- 
gastrium ; or  else  frictions  of  that  region  with  tartar-emetic  ointment. 
We  may  also  use,  with  advantage,  infusions  of  linden-flowers,  of 
orange-flowers,  or  of  chamomile,  sweetened  with  a little  syrup  of 
poppy-heads  or  of  ether.  There  have  been  recommended,  also,  the 
subnitrate  and  white  oxyde  of  bismuth,  in  the  dose  of  four  to  six 
grains,  administered  at  two  or  three  different  times  in  the  day,  in  a 
spoonful  of  sweetened  water  or  syrup.  We  have  always  prescribed, 
with  greater  advantage,  the  extract  of  valerian  and  subcarbonate  of 
iron  in  the  pilular  form.  We  have  likewise  obtained  good  results, 
sometimes,  by  directing  the  internal  use  of  ice,  or  else  of  a small 
quantity  of  Garus’s  elixir,  especially  for  the  purpose  of  diminishing 
or  dispelling  the  paroxysms.  Finally,  we  must  associate  with  the 
employment  of  these  means  a regimen  composed  of  aliments  of  easy 
digestion,  and  the  use  of  tea  after  the  meals,  and  of  the  gaseous 
waters  of  Seitz  or  of  St.  Albans,  mixed  with  wine  and  taken  with  the 
food. 


604 


ENTERALGIA,  CONSTIPATION. 


OF  ENTERALGIA. 

There  is  another  form  of  neuralgia,  to  which  pregnant  women  are 
subject;  that  which  is  known  by  the  name  of  enteralgia  or  nervous 
colic.  This  affection,  which  depends  upon  a spasmodic  and  sym- 
pathetic condition  of  pregnancy,  generally  prevails  in  the  early 
months,  in  the  form  of  intermittent,  shifting  pains,  unaccompanied 
by  febrile  movements,  however  severe  they  may  be,  and  which  are 
not  increased  by  pressure  upon  the  abdominal  parietes. 

This  kind  of  colic,  which  may  also  be  occasioned  by  cold,  requires 
nearly  the  same  treatment  as  gastralgia,  that  is  to  say,  we  must 
oppose  it  by  baths,  poultices,  fomentations,  and  emollient  and  ano- 
dyne enemata,  as  well  as  by  infusions  of  linden-flowers,  of  chamo- 
mile, and  of  tea  sweetened  with  syrup  of  ether  and  of  poppy-heads. 
Barthez  recommended,  in  such  cases,  a bolus  composed  of  camphor, 
nitrate  of  potash  and  assafoetida.  If  flatulence  accompany  these 
symptoms,  we  might  relieve  it  by  frictions  with  the  baume  tran- 
qiiille , or  by  warm  poultices  sprinkled  with  oil  of  hyoscyamus  or 
chamomile,  upon  the  abdomen.  Lastly,  should  there  be  any  symp- 
toms of  plethora  or  inflammation,  bleeding  must  be  resorted  to. 

OF  CONSTIPATION. 

Constipation  is  very  common  in  pregnant  women,  especially  to- 
wards the  end  of  pregnancy : it  is  generally  caused  by  the  pressure 
of  the  enlarged  womb  upon  the  colon  and  rectum,  whence  results 
difficulty  in  the  passage  of  the  fecal  matter.  It  may  depend  also 
upon  a vital  lesion  or  intestinal  neurosis  connected  with  the  spasmo- 
dic irritation  of  the  uterine  system.  Whatever  be  the  cause  of  the 
difficulty,  when  it  is  carried  to  some  extent,  it  produces  anorexia, 
renders  the  digestion  difficult,  causes  restlessness,  insomnia,  cephal- 
algia, sadness  and  capricious  temper.  The  efforts  made  by  the  female 
to  expel  the  abundant  and  hardened  fecal  matter,  may  become  a 
source  of  uterine  haemorrhage,  and  even  of  abortion ; while  the  con- 
tinual pressure  of  the  excrements  upon  the  extremity  of  the  intes- 
tine, may  determine,  at  that  point,  inflammation  and  haemorrhoidal 
tumours. 

Moreover,  the  constipation  exists  in  different  degrees.  When  it 
does  not  last  more  than  three  days,  most  women  are  little  disturbed 
by  it ; but  when  the  stools  occur  at  longer  intervals,  it  may  give  rise 
to  all  the  inconveniences  we  have  pointed  out. 

It  is  of  the  utmost  importance,  therefore,  to  prevent  or  dissipate, 
or  at  least  to  diminish  the  unfavourable  effects  of  constipation  in 
pregnant  women.  It  must  be  treated  by  various  means,  except  the 
drastic  purgatives,  the  use  of  which  may  occasion  the  most  danger- 
ous accidents.  It  is,  however,  upon  a mild  and  relaxing  regimen  that 
we  should  chiefly  rely : thus  we  may  with  advantage  prescribe  the 
white  meats;  dressed  vegetables,  particularly  sorrel,  lettuce  and  spi- 
llage ; cooked  or  very  ripe  fruits,  such  as  cherries,  melons,  grapes, 
prunes,  strawberries  and  oranges.  It  is  well  to  add  to  these  dietetic 


DIARRHOEA,  DYSENTERY,  TENESMUS.  605 

means,  the  employment  of  warm  baths,  the  use  of  vegetable  or  veal 
soup,  lemonade,  cream  of  tartar,  milk  weakened  with  water,  decoc- 
tions of  tamarinds,  cassia  fistula,  or  of  prunes,  and  barley-water 
sweetened  with  honey,  according  to  the  taste  of  the  patient  and  the 
effects  produced. 

Should  these  measures  not  be  sufficient,  we  must  recommend  emol- 
lient and  laxative  enemata,  prepared  with  brown  sugar,  honey,  senna, 
French  mercury,  oil  or  butter.  We  may  likewise  employ  the  mild 
purgatives,  such  as  manna,  castor  oil,  Seidlitz  water  or  phosphate  of 
soda.  We  have  treated  the  obstinate  constipations  of  pregnant 
women  successfully, 'by  means  of  suppositories  of  benrre  de  cacao , 
employed  three  times  a day,  and  a grain  of  calomel  taken  at  night, 
on  going  to  bed,  in  half  a tumbler  of  sweetened  water.  Finally,  in 
some  bad  cases,  when  the  fecal  matters  are  so  impacted  in  the 
intestine  as  to  make  it  impossible  to  expel  them  by  enemata  and 
purgatives,  it  becomes  indispensable  to  extract  a large  portion  of 
the  mass  with  the  finger  or  a scoop.  The  impossibility  of  intro- 
ducing a canula  or  of  injecting  fluids  into  the  rectum,  indicates  the 
accidental  occlusion  of  the  intestine,  and  should  decide  the  physician 
to  remedy  it  as  soon  as  possible,  by  the  use  of  the  finger.  It  is  proper 
to  remark,  further,  that  in  some  subjects,  frictions  of  the  abdomen, 
the  application  of  a cold  body,  as  ice,  to  the  soles  of  the  feet,  just  as 
the  use  of  beer  or  coffee,  especially  if  a glass  of  water  be  taken  after- 
wards, almost  immediately  produce  an  evacuation  of  the  fecal  mat- 
ters. 

OF  DIARRHOEA,  DYSENTERY  AND  TENESMUS. 

The  diarrhoea  of  pregnant  females,  which  consists  of  a more  or 
less  frequent  evacuation  of  mucous,  serous  or  bilious  matters,  depends 
almost  always  upon  a nervous  cause,  that  is  to  say,  it  depends  upon 
the  sympathetic  influence  of  the  uterus  upon  the  digestive  canal.  In 
some  cases,  however,  the  diarrhoea  is  produced  by  an  intestinal  irrita- 
tion, which  betrays  itself  by  sensibility  of  the  abdomen,  by  heaviness 
of  the  head,  by  a saburral  condition,  by  a mucous  coat  upon  the 
tongue,  by  difficulty  of  digestion,  and  elevation  of  the  pulse.  In  the 
sympathetic  or  nervous  diarrhoea,  the  patients  are  without  fever,  or 
colic;  the  mouth,  tongue  and  appetite  retain  their  normal  condition. 

When  the  evacuations  are  mixed  with  blood,  it  takes  the  name  of 
dysentery,  which  is  always  the  result  of  an  irritation  of  the  intestines, 
and  which  is  generally  accompanied  by  fever,  colic,  tension  and 
sensibility  of  the  abdomen.  Lastly,  the  disease  receives  the  title  of 
tenesmus,  when  it  consists  of  a constant,  painful  and  nearly  unavail- 
ing desire  to  go  to  stool,  and  when  accompanied  by  burning  heat  at 
the  fundament.  The  last-named  affection  generally  occurs  towards 
the  end  of  pregnancy ; and  the  straining  which  results  from  it  has 
been  known  to  produce  abortion.  The  compression  exerted  upon  the 
rectum,  and  the  constipation  thereby  produced  may  sometimes  give 
rise  to  tenesmus;  but  this  affection  commonly  depends  upon  the 
diarrhoea  or  dysentery. 


606 


DYSPNOEA. 


A diarrhoea  occurring  at  the  commencement  of  pregnancy,  is  com- 
monly of  little  consequence ; as  the  woman  retains  her  appetite 
and  strength,  it  may  be  left  to  nature,  or,  at  least,  treated  simply  by 
careful  diet,  rice  water,  and  emollient  enemata.  Should  there  be 
symptoms  of  gastric  or  intestinal  irritation,  and  especially  if  the 
tongue  be  coated  and  give  evidence  of  a saburral  condition,  resort 
must  be  had  to  the  employment  of  demulcent  and  anodyne  enemata, 
drinks  of  the  same  kind,  baths,  fomentations  and  poultices;  and 
even  to  an  application  of  leeches  ^about  the  anus,  particularly  in 
women  of  strong  and  plethoric  constitutions.  In  some  cases,  evacu- 
ants  also  are  prescribed ; ipecacuanha  in  a dose  of  several  grains, 
and  infusion  of  rhubarb,  with  addition  of  four  drachms  of  sulphate 
of  soda.  If,  notwithstanding  the  use  of  these  means,  the  diarrhoea 
should  persist,  and  especially  if  the  woman  loses  her  strength,  we 
must  resort  to  the  bitters,  such  as  gentian,  the  lesser  centaury,  rhu- 
barb, infusion  of  chamomile,  and,  after  a proper  time,  to  wine  of  ab- 
sinthium, to  Bordeaux  wine,  to  diascordium,  to  theriac.,  and  to  opiates. 
It  will  be  well,  also,  to  use  tonic  and  sedative  enemata,  prepared  with 
a weak  decoction  of  cinchona  and  a few  drops  of  laudanum. 

In  the  treatment  of  dysentery,  we  must  recur  to  opiate  prepara- 
tions chiefly ; for  example,  opium  is  to  be  prescribed  in  all  its  forms. 
For  ordinary  drink,  the  patients  should  make  use  of  rice  water  with 
gum,  with  the  addition  of  fifteen  drops  of  Sydenham’s  laudanum; 
they  should  use,  two  or  three  times  in  the  day,  enemata  of  decoction 
of  althaea  or  flaxseed,  with  twenty-five  drops  of  laudanum.  Lastly, 
there  is  a remedy  which  has  always  succeeded  in  our  hands,  consisting 
of  a mixture  of  the  whites  of  six  eggs,  beaten  in  a quart  of  water, 
to  be  taken  both  as  a drink  and  as  enemata.  Care  must  be  observed  to 
use  enemata,  of  small  size  only,  several  times  a day;  and  they  ought 
to  be  retained,  if  possible.  The  portion  of  the  same  liquid  which  is 
used  as  drink,  ought  to  be  sweetened  with  sugar,  or,  still  better,  with 
half  a tablespoonful  of  syrup  of  poppies,  to  every  glass.  The  two 
last  means  are  particularly  useful  when  the  dysentery  is  complicated 
with  tenesmus,  which  requires  nearly  the  same  treatment  as  dysen- 
tery. 

The  power  of  these  remedies  may  be  assisted  by  dieting,  or  by  an 
analeptic  regimen,  composed  principally  of  moderately  rich  soups, 
feculent  substances,  animal  jellies,  white  meats,  fresh  eggs  in  the 
shell,  and  of  substances  of  easy  digestion. 

OF  DYSPNCEA. 

Affections  of  the  Respiratory  Organs  during  Pregnancy. 

Several  sorts  of  dyspnoea  often  accompany  the  pregnant  state. 
The  first,  which  is  a nervous  dyspnoea,  generally  appears  in  the 
early  periods  of  the  gestation,  and,  for  its  principal  character,  has 
intermissions,  and  returns  in  regular  or  irregular  paroxysms. 

The  second  species  of  dyspnoea,  which  is  generally  more  painful 
than  the  first,  and  which  has  been  looked  upon  as  the  result  of  pie- 


DYSPNCE  A. 


607 


thora,  occurs  more  particularly  towards  the  fifth  month,  and  is 
without  intermissions.  Finally,  the  last  species,  observed  towards 
the  end  of  pregnancy,  depends  upon  the  size  of  the  uterus,  which 
presses  up  the  diaphragm,  and  thereby  lessens  the  capacity  of  the 
chest.  This  difficulty  of  respiration  is  remarked  principally  in  women 
who  have  narrow  chests  and  contracted  pelvis;  in  primipara,  in 
those  who  are  rather  under  size,  and  lastly,  in  those  affected  with 
some  deviation  or  deformity.  In  this  condition  the  oppression  is 
so  great  sometimes  as  to  produce  a state  bordering  upon  suffocation. 
The  patients  are  always  obliged  to  maintain  a nearly  vertical  posi- 
tion, or  to  place  themselves  on  their  knees  upon  cushions,  with  the 
elbows  resting  upon  other  and  more  elevated  cushions,  in  order,  in 
this  way,  to  obtain  a little  sleep,  or  at  least  repose.  Desormeaux, 
who  relates  the  case  of  a lady  who  was  deformed  and  was  affected 
with  this  species  of  dyspnoea,  adds  that  she  was  threatened  with 
suffocation  whenever  she  leaned  backwards  or  quitted  the  position 
we  have  just  described.  The  same  author  says  that  the  above 
patient,  who  always  had  imperfect  respiration,  swelled  face,  and 
bluish  lips,  was  forced  to  remain  standing  during  the  whole  of  the 
labour,  which  was  long  and  painful,  and  could  not  be  terminated 
until  the  head  of  the  child  had  been  opened  and  the  brain  evacuated. 
Moreover,  she  died  three  days  after  the  labour  without  pain  or 
fever,  and  seemed  to  perish  by  a slow  asphyxia.  At  the  autopsy, 
the  lungs  were  found  to  have  been  forced  into  the  superior  part  of 
the  thorax,  to  be  of  compact  consistence,  of  a brownish-red  colour, 
and  crepitant  in  a very  small  portion  only. 

The  treatment  of  nervous  dyspnoea  or  that  which  occurs  in  the 
early  months  of  pregnancy,  consists  in  the  employment  of  antispas- 
modics  and  sedatives,  amongst  others  the  infusion  of  orange-flowers 
and  linden-flowers,  syrup  of  poppies,  cherry  laurel  water,  and  the 
medicinal  hydrocyanic  acid ; camphor,  assafoetida,  musk,  and  castor 
in  mixture  or  pill ; lastly,  sulphate  of  quinine  combined  with  opium, 
should  the  difficulty  of  respiration  affect  an  intermittent  type. 

The  plethoric  dyspnoea  is  to  be  treated  by  bleeding,  to  the  amount 
generally  of  eight  or  ten  ounces,  which  is  sufficient  to  relieve  the 
lungs  and  facilitate  the  entrance  of  the  quantity  of  air  necessary  for 
respiration.  There  should  be  prescribed,  at  the  same  time,  a more 
severe  regimen,  and  some  laxatives  and  enemata  in  order  to  keep  the 
bowels  soluble. 

To  oppose  the  last  species  of  dyspnoea,  the  patient  must  be  recom- 
mended to  take  a position  most  favourable  to  respiration,  which  con- 
sists in  maintaining  a nearly  erect  posture,  with  the  head  and  chest 
sustained  by  means  of  cushions  disposed  in  the  way  found  to  be  most 
agreeable.  A bleeding  from  the  arm  is  generally  employed  for  the 
purpose  of  preventing  vertigo  and  a sense  of  suffocation,  and  to 
relieve  as  much  as  possible  the  pulmonary  vessels.  Finally,  the 
patient  should  be  subjected  to  a mild  diet,  she  should  be  allowed 
small  quantities  only  of  food  at  each  meal,  in  order  to  avoid  distension 
of  the  stomach,  while  substances  difficult  of  digestion,  especially  those 
which  produce  extrication  of  gases,  must  be  forbidden.  The  size  of 


60S 


DYSPNCEA. 


the  abdomen  is  to  be  diminished  as  much  as  possible,  by  means  of 
enemata  and  laxative  drinks,  and  all  articles  of  clothing  that  com- 
press the  thorax  and  abdomen,  and  prevent  their  expansion  during 
respiration,  ought  to  be  removed.  It  is  proper  to  remark,  also,  that 
if  the  dyspnoea  depend  upon  an  organic  affection  of  the  lungs  exist- 
ing before  conception,  but  which  has  been  aggravated  by  gestation, 
the  treatment  must  be  directed  towards  the  affection  which  is  the 
cause  of  it,  remembering,  however,  its  complication  with  the  preg- 
nant state. 

[I  have  met  with  many  cases  of  dyspnoea  in  pregnant  females ; and  ex- 
cept in  those  instances  where  the  oppression  of  the  chest  is  derived  from  the 
pressure  against  the  diaphragm  from  below,  I think  they  are  always  worthy 
of  a close  and  most  careful  scrutiny — since  it  is  dangerous  to  permit  the 
difficulty  to  continue,  when  it  is  possible  to  obviate  it,  under  the  very 
loose  general  idea  of  its  being  one  of  the  diseases  of  pregnancy. 

The  pressure  of  the  gravid  womb  upon  the  abdominal  aorta,  and  the  branches 
of  the  cceliac  and  the  mesenteric  arteries,  as  well  as  its  intrusive  interference 
with  the  descent  of  the  diaphragm,  are  all  highly  provocative  of  excessive 
determination  of  blood  to  the  head,  the  superior  extremities  and  the  thoracic 
viscera.  Hence  we  very  frequently  meet  with  the  cephalalgia,  the  convul- 
sion, the  mania,  and  the  altered  temper  of  the  pregnant  female,  in  dependence 
mainly  on  simple  excessive  determination  of  blood  to  the  superior  parts 
of  the  body,  from  pressure  on  the  aorta.  But  the  same  disposition  also 
exists  as  to  the  pulmonary  circulation,  and  is  shown  in  the  engagements,  the 
dyspnoea,  and  the  altered  colour  of  the  cheeks,  lips  and  fauces,  in  the  cough, 
and  mucous  rale,  in  the  palpitation,  and  also  in  the  vascular  reaction  conco- 
mitant of  such  conditions. 

Where  a patient  under  gestation  makes  complaints  on  the  subject  of  her 
respiration,  it  requires  but  little  time  carefully  to  auscult  every  part  of  the 
lungs  and  the  heart,  and  pericardium.  This,  and  the  test  of  the  capacity  of 
the  lungs  for  air,  obtained  by  causing  the  patient  to  make  a forced  inspira- 
tion, may  clear  up  the  diagnosis  and  leave  us  assured  that  nothing  is  to  be 
feared  ; or  direct  us  to  the  prosecution  of  vigorous  measures  for  the  cure.  I 
have  for  the  most  part  found  that  a patient  attacked  with  inflammation  of  the 
lungs,  is  not  very  easily  cured,  if,  in  an  advanced  stage  of  pregnancy,  until 
after  her  delivery  shall  have  taken  place.  Upon  the  withdrawal  of  the 
pressure  and  the  distension,  the  restoration  of  a free  excursus  to  the  blood 
enables  the  disordered  lung  to  recover  rapidly,  provided  no  mischief  has  been 
done  to  the  organ  in  the  mean  time.  But  as  there  is  great  danger  that  such 
mischief  may  be  done,  a patient  so  complaining  ought  to  be  made  aware  of 
the  risk,  and  put  at  once  under  a regular  clinical  treatment. 

Many  women  complain  of  a difficult  respiration  in  pregnancy,  and  of  vio- 
lent palpitation  and  unusual  disorder  of  the  heart,  in  consequence  of  their 
having  become  anaemic  during  the  last  months  or  weeks  of  the  gestation. 

I am  quite  certain  that  pregnancy  is  a not  unfrequent  cause  of  the  anaemic 


COUGH. 


609 


malady — and  where  the  anaemia  proceeds  to  an  aggravated  state,  the  conse- 
quences are  often  most  distressing — for  during  the  existence  of  a great  dimi- 
nution of  the  crasis  of  the  blood,  the  patient  is  liable  to  troublesome  and 
even  very  dangerous  effusions  of  serum  into  the  chest,  the  pericardium  and 
the  abdomen.  A mistake  on  the  part  of  the  practitioner  would  be  very  un- 
fortunate for  the  patient,  by  misleading  him  in  the  method  of  treatment. 
Let  him  therefore  carefully  discriminate  betwixt  the  effects  of  a pure  inflam- 
mation, and  those  often  similar  ones  that  arise  out  of  the  feeble  and  irregu- 
lar innervation  proceeding  from  a state  of  the  blood,  in  which  that  fluid 
has  lost  a large  portion  of  its  power  to  excite  the  brain  and  nervous  sys- 
tem, leaving  them  subject  to  the  utmost  incompetency  to  fulfil  their  office. 
Where  the  blood  has  become  imperfect  by  the  loss  of  a quota  of  its  discs  or 
its  albumen,  it  is  not  possible  that  the  brain  and  nerves  should  steadily  and 
properly  innervate  the  heart — the  respiratory  organs,  nor  indeed  any  portion 
of  the  organisms. — M.]| 


OF  COUGH. 

The  cough,  like  the  dyspnoea  which  attacks  women  in  the  early 
months  of  pregnancy,  depends  upon  a nervous  condition  which  is 
the  result  of  the  sympathetic  influence  of  the  womb  upon  the  pul- 
monary organs.  The  nervous  cough,  though  the  least  dangerous  of 
all,  must  be  distinguished  from  that  which  is  the  result  of  a bron- 
chitis or  of  a pulmonary  congestion,  for  the  therapeutical  means  which 
it  requires  are  totally  different.  In  the  nervous  cough,  there  is  no 
expectoration,  and  the  cough  is  always  dry,  unless  complicated  by  a 
cold  ; the  catarrhal  cough  produced  by  cold,  is  on  the  contrary  accom- 
panied by  mucous  expectoration,  coryza,  often  by  soreness  of  the 
throat,  by  dull  pain  in  the  head,  and  by  a slight  rigor  in  the  evening 
with  or  without  fever;  none  of  these  symptoms  occur  in  the  nervous 
cough. 

That  which  is  produced  by  a pulmonary  engorgement  generally 
appears  towards  the  end  of  the  pregnancy.  Its  exciting  cause  is  the 
augmentation  of  size  of  the  uterus,  which  presses  up  the  diaphragm 
and  intestines,  and,  by  consequence,  lessens  the  thoracic  cavity.  Un- 
der these  circumstances,  the  pulse  of  the  patient  is  hard  and  full,  the 
countenance  red  and  animated ; she  complains  of  headache,  of  un- 
easiness and  oppression,  especially  after  eating,  and  some  are  subject 
to  nasal  or  bronchial  haemorrhages. 

In  general,  be  the  character  and  cause  of  the  cough  what  they 
may,  it  is  a symptom  which  ought  to  command  the  attention  of  the 
physician,  because  the  violent  shocks  which  it  imparts  to  the  abdomi- 
nal viscera  may  become  the  causes  of  uterine  haemorrhage  and  abor- 
tion, or  be  extremely  inconvenient,  at  least  in  some  cases,  by  exciting 
sudden  and  involuntary  expulsion  of  the  urine.  • Moreover,  the 
cough,  whose  violence  is  generally  increased  by  the  phenomena  ot 
gestation,  may,  by  its  prolongation,  determine  pulmonary  inflamma- 
tion, or  have  the  inconvenience  at  least  of  increasing  in  severity  after 
39 


610 


HEMORRHAGE  IN  PREGNANCY. 


the  labour,  which  does  not  generally  occur  in  regard  to  the  other 
complications  of  pregnancy. 

The  treatment  of  the  nervous  cough  consists  in  the  employment 
of  opiates  when  it  is  slight,  and  of  bleeding  when  violent  and  con- 
tinued. To  these  means  may  be  added  tinctures,  mucilaginous 
drinks,  the  bechic  infusions  of  violets,  calf’s  foot,  hyssop,  wild  poppy 
or  borage,  sweetened  with  syrup  of  gum,  of  erysimum  or  maiden- 
hair, sinapisms  to  the  limbs,  laxative  enemata,  and,  lastly,  frictions 
with  Autenrieth’s  antimonial  ointment  upon  the  sternum.  The 
same  means,  and  particularly  the  bleeding,  may  be  opposed  to  the 
cough  which  depends  upon  a pulmonary  engorgement : the  same  is 
true  of  the  catarrhal  cough,  which  less  frequently  requires  sanguine 
emissions,  and  which  is  generally  treated  successfully,  when  chronic, 
by  means  of  a tisan  of  Iceland  moss,  taken  with  a little  milk  or 
sweetened  with  syrup  of  maiden-hair  or  erysimum. 

OF  HEMORRHAGES  OCCURRING  DURING  PREGNANCY. 

Uterine  Haemorrhages. 

Amongst  the  losses  of  blood  to  which  pregnant  women  are  sub- 
ject, there  is  none  more  frequent  and  dangerous  than  that  from  the 
uterus.  This  haemorrhage,  whose  predisposing  causes  are  all  the 
circumstances  that  we  assigned  to  the  other  metrorrhagias  independ- 
ent of  pregnancy,  may  be  occasioned  by  any  of  the  causes  capable 
of  producing  abortion,  amongst  others,  by  the  criminal  manoeuvres 
which  some  persons  make  use  of,  by  means  of  puncturing  instruments 
introduced  into  the  uterus,  or  by  making  use  of  violent  emetics 
and  purgatives,  by  emmenagogues,  hip-baths,  bleedings,  leeches,  etc. 
Blows  upon  the  abdomen;  falls  on  the  feet, knees  or  breech;  violent 
movements  of  the  limbs,  forced  walking,  dancing ; abuse  of  coitus, 
and  all  efforts  and  sudden  or  violent  shocks  may  also  give  rise  to  it. 
The  uterine  haemorrhage  of  pregnant  women  is  particularly  caused 
by  separation  of  the  foetal  membranes  from  the  internal  surface  of 
the  womb,  and  by  vicious  insertion  of  the  placenta  over  the  cervix 
uteri.  The  haemorrhage  due  to  this  cause  generally  appears  without 
precursory  symptoms  from  the  sixth  to  the  seventh  months  of  preg- 
nancy, because  about  this  period  the  cervix  uteri  begins  to  diminish 
in  length  and  to  enlarge  its  orifice. 

This  metrorrhagia  may  be  apparent  or  concealed,  that  is  to  say, 
external  or  internal.  In  the  former  case,  it  is  recognized  by  the 
escape  from  the  vulva  of  a larger  or  smaller  quantity  of  blood ; and, 
unless  it  depend  on  anormal  insertion  of  the  placenta,  is  preceded  by 
dull  pain,  by  weight  in  the  hypogastrium,  and  by  dragging  in  the 
loins  and  groins.  In  the  second  case,  the  diagnosis  is  more  diffi- 
cult; for  the  blood  may  be  retained  by  occlusion  of  the  cervix,  by 
adhesions  which  confine  the  liquid  behind  the  foetal  membranes, 
and,  lastly,  by  the  placenta,  which,  separated  at  the  centre  and  not 
at  the  edges,  forms  a sort  of  sac  in  which  the  sanguine  effusion 
accumulates.  , Under  these  circumstances,  the  haemorrhage  can  be 


UTERINE  HAEMORRHAGE. 


611 


suspected  only  from  the  internal  phenomena  showing  congestion  of 
the  uterus,  such  as  increased  size  of  the  abdomen  and  deep-seated 
pains  in  the  pelvis  and  loins,  to  which  after  a time  are  added  pale- 
ness of  the  face,  faintness,  feeble  pulse  and  vision,  tinnitus  aurium, 
general  sensation  of  coldness  and  often  syncope.  Hemorrhages  of 
this  kind  take  place  without  being  preceded  by  prodromic  symptoms; 
they  are  at  first  slight  and  of  short  duration,  but,  after  a longer  or 
shorter  period  of  time,  they  reappear  in  larger  and  larger  quantity 
and  last  longer.  The  finger  carried  into  the  os  uteri,  finds  it  filled 
with  the  thick,  unequal  and  spongy  substance  of  the  placenta,  always 
easy  to  distinguish  from  the  clots  of  blood  which  may  be  detained 
there,  and  which  are  always  of  softer  consistence  and  smoother  sur- 
face ; lastly,  by  means  of  ballottement,  we  discover  that  there  is 
some  intermediate  body,  more  or  less  thick,  between  the  finger  and 
the  foetus.  Moreover,  the  successive  haemorrhages  exhaust  the 
patient,  render  the  muscles  oedematous,  and  soon  produce  white- 
ness of  the  lips  and  puffiness  of  the  face,  whose  colour  becomes  yel- 
low and  dull  like  wax. 

Metrorrhagia  occurring  in  the  early  months  of  pregnancy,  is  gene- 
rally less  dangerous  for  the  female  than  for  the  fetus,  for  it  is  very 
often  followed  by  abortion.  In  the  latter  months,  on  the  contrary, 
the  mother  runs  more  risk  than  the  child.  Internal  haemorrhage  is 
always  more  dangerous  than  external;  just  as  the  loss  of  blood, 
which  occurs  from  the  placenta  or  cord,  exposes  the  fetus  to  greater 
danger  than  the  woman ; the  contrary  is  true  where  it  is  due  to  an 
uterine  exhalation.  It  is  proper  to  remark,  also,  that  in  haemorrhage 
depending  upon  a plethoric  condition,  the  flow  of  blood,  by  destroy- 
ing the  molimen,  arrests  the  disorder  itself.  It  thus  becomes  its 
principal  remedy. 

The  treatment  of  uterine  haemorrhages  of  small  amount,  and 
which  have  occurred  accidentally  in  the  early  months  of  pregnancy, 
consists  in  moderating  the  general  circulation  and  diminishing  the 
afflux  of  blood  towards  the  uterus.  This  double  indication  is 
answered  by  placing  the  woman  in  a horizontal  position  on  a hard 
bed,  and  adjusting  the  pelvis  in  such  a way  that  it  shall  be 
higher  than  the  rest  of  the  body.  Fresh  and  pure  air,  repose  of 
the  body  and  mind,  rigorous  diet,  and  cold  acidulated  drinks  are 
indispensable.  If  the  patient  be  strong  and  of  sanguine  constitution, 
we  may  resort  to  bleeding,  taking  care  to  make  a very  small  orifice 
in  the  vein,  so  that  the  blood  may  flow  as  long  as  possible.  The 
same  result  might  be  obtained  by  applying  the  finger  to  the  wound, 
and  then  removing  it  from  time  to  time  in  order  to  let  the  blood 
escape.  If  the  haemorrhage  should  continue,  in  spite  of  these  means, 
we  must  resort  to  refrigerants  and  to  applications  of  compresses,  wet 
with  cold  water  or  oxycrate,  to  the  abdomen  and  inside  of  the 
thighs.  We  might  employ,  likewise,  the  large  dry  cups  under  the 
breasts,  mustard  hand-baths,  and  mustard  poultices  between  the 
shoulders,  according  to  the  advice  of  M.  Velpeau.  There  should  be 
prescribed,  also,  especially  for  feeble  women,  a sedative  mixture, 
composed  of  lettuce  water,  extract  of  rhatany  and  syrup  of  comfrey, 


612 


UTERINE  HAEMORRHAGE. 


which  ought  to  be  substituted  by  syrup  of  opium  and  ether  if  the 
patient  be  very  nervous  and  irritable. 

Should  the  haemorrhage  persist  and  threaten  to  prove  fatal,  not- 
withstanding the  employment  of  these  means,  which  are  proper 
principally  in  the  early  months,  the  only  chance  of  saving  the  patient 
that  remains,  is  to  empty  the  uterus.  The  moment  which  calls  for 
this  proceeding,  is  that  when  the  constantly  increasing  paleness  and 
debility,  the  small  size  of  the  pulse  and  faintings,  indicate  a pressing 
danger  and  one  beyond  the  other  resources  of  the  Art.  But  as  the 
womb  is  often  not  sufficiently  developed  to  allow  of  the  introduction 
of  the  hand  into  its  cavity,  the  membranes  ought  not  to  be  rup- 
tured. It  is  then  only  that  the  tampon  is  useful,  by  permitting  the 
blood  to  accumulate  in  the  uterus,  the  os  uteri  to  be  dilated  and  soft- 
ened, the  ovum  to  detach  itself,  favouring  in  this  way  the  expulsion 
of  the  foetus.  If  the  sanguine  discharge  persist,  notwithstanding 
the  presence  of  the  tampon,  we  must  endeavour  to  bring  on  con- 
tractions of  the  uterus  by  means  of  irritating  enemata,  and  act  after- 
wards as  in  ordinary  cases  of  abortion.  Lastly,  if,  on  the  contrary, 
the  dilatation  and  thinning  of  the  cervix  permit,  first  one,  then  two, 
and  then  three  fingers  must  be  carried  into  the  os  uteri,  and,  as 
soon  as  the  bag  of  waters  is  formed,  without  waiting  for  complete 
dilatation,  the  membranes  are  to  be  perforated  and  the  expulsion 
of  the  foetus  to  be  trusted  to  nature,  assisted  by  means  of  titiilations 
of  the  os  uteri  and  frictions  to  the  hypogastrium.  Should  the  child 
be  in  a bad  position,  it  would  be  necessary,  after  the  rupture  of  the 
membranes,  to  carry  the  hand  into  the  uterus,  search  for  the  feet, 
and  turn  the  child.  Ergot  might  often  be  useful  in  cases  of  this 
kind,  to  prevent  inertia  of  the  uterus,  which  is  to  be  apprehended 
after  too  rapid  a delivery. 

[In  one  of  the  sentences  of  this  paragraph  M.  Colombat  says,  that  in 
uterine  haemorrhage,  in  the  pregnant  woman,  when  the  cervix  is  not  suffi- 
ciently dilated  to  admit  the  hand,  the  tampon  becomes  useful,  and  only 
then , ( settlement  alors.) 

I am  much  gratified  with  the  appearance  of  carefulness  with  which  the 
author  has  pronounced  this  opinion,  settlement  alors.  I add  this  note 
for  the  sole  purpose  of  endeavouring  to  impress  the  value  of  this  direc- 
tion more  deeply  upon  the  mind  of  the  young  practitioner,  f have,  in 
another  note,  given  my  opinion,  that  the  tampon  is  a resource  of  the 
greatest  value  in  uterine  haemorrhages  of  the  pregnant  woman  who  has  not 
passed  much  beyond  her  fourth  month ; but  I have  a feeling  amounting 
almost  to  horror,  of  the  practice  of  introducing  the  tampon  in  an  advanced 
stage  of  gestation — since  when  blood  is  effused  from  the  vessels  it  can 
never  be  reabsorbed  by  them,  and  the  sooner  it  is  removed  from  the  cavity 
the  better.  I disapprove  of  the  tampon  even  in  placenta  praevia ; and  I 
am  glad  to  find  that  Robt.  Lee,  in  his  beautiful  little  volume,  Clinical  Mid- 
wifery, is  of  the  same  opinion. — M.] 

The  uterine  haemorrhages  occurring  during  labour,  generally  depend 


UTERINE  HAEMORRHAGE. 


613 


upon  the  same  causes  as  the  preceding,  particularly  upon  a plethoric 
condition  of  the  female  and  on  placenta  prasvia ; to  these  should  be 
added,  more  or  less  serious  lacerations  of  the  uterus  and  vagina  and 
rupture  of  the  umbilical  cord.  Moreover,  the  haemorrhages  which 
appear  during  labour,  are  so  much  the  less  dangerous  as  this  is  more 
advanced,  for  when  the  uterus  is  emptied  it  generally  contracts,  and, 
in  this  way,  the  flow  of  the  blood  is  arrested ; the  treatment  ought 
to  consist,  therefore,  in  the  employment  of  means  proper  to  accele- 
rate delivery.  The  accoucheur  must  determine,  in  these  cases, 
between  the  ergot,  the  tampon,  the  rupture  of  the  membranes,  the 
forceps  and  version.  Haemorrhage  during  labour  is  one  of  the  most 
dangerous  forms  of  that  accident,  especially  if  it  depend  on  inertia 
of  the  womb.  It  may  be  occasioned,  also,  by  plethora,  by  vivid 
emotions,  by  the  presence  of  the  placenta,  by  a portion  of  that  body 
or  of  any  other  substance  in  the  uterus,  by  more  or  less  complete 
inversion  of  the  organ,  and,  finally,  by  laceration  of  the  cervix. 
These  hemorrhages  may  be  either  internal  or  external,  like  those 
which  appear  during  pregnancy  or  labour.  We  call  attention  to  the 
fact  merely,  that  internal  uterine  haemorrhage  is  never  more  frequent 
or  more  dangerous  than  after  labour. 

The  treatment  of  flooding  varies  according  to  the  cause  which 
produces  it.  If  it  be  the  placenta,  a clot  of  blood  or  any  other  body 
preventing  the  contraction  of  the  womb,  it  must  be  extracted.  — 
If  the  haemorrhage  depend  upon  laceration  of  the  cervix,  it  may  be 
arrested  by  means  of  a tampon  of  charpie,  sprinkled  with  pow- 
dered alum  and  resin,  carried  up  to  the  seat  of  the  mischief.  Again, 
bleeding  must  be  used  in  cases  determined  by  a plethoric  state,  and 
the  reduction  of  the  womb  in  those  produced  by  inversion  of  that 
organ.  Finally,  we  may  join  to  the  other  means,  especially  to  the 
external  refrigerants  and  derivations  indicated  for  the  arrest  of 
haemorrhage  during  pregnancy,  the  introduction  of  a peeled  lemon 
into  the  cavity  of  the  uterus,  and  compression  of  the  aorta  above 
the  sacro- vertebral  angle,  either  by  acting  upon  the  uterus  through 
the  walls  of  the  abdomen,  by  means  of  a hand  carried  into  the 
uterus  so  as  to  compress  the  aorta  against  the  vertebral  angle,  or, 
lastly,  by  making  the  compression  above  the  uterus,  by  means  of 
the  fingers  acting  through  the  abdominal  parietes.  As  to  haemor- 
rhages dependent  upon  inertia  of  the  womb,  we  refer  to  the  chapter 
which  treats  of  them.  The  same  applies  to  the  inversion  of  the 
organ. 

[In  the  treatment  of  uterine  haemorrhages,  it  is  of  the  utmost  importance 
to  understand  the  uses  and  value  of  position,  as  a means  of  diminishing  or 
suppressing  the  flooding. 

In  all  floodings  at  or  near  the  full  term  of  utero-gestation,  the  woman 
should  lie  upon  the  bed,  with  the  head  but  slightly  raised,  while  the 
shoulders  are  upon  the  same  plane  with  the  rest  of  the  trunk.  If  the 
haemorrhage  be  an  alarming  one,  it  might  be  that  the  medical  attendant  * 
should  find  a full  and  bounding  pulse,  with  a decided  heat  of  the  skin 


614 


UTERIXE  HAEMORRHAGE. 


and  flushing  of  the  face.  In  such  a case  he  ought,  without  hesitation,  to 
let  blood  at  the  arm,  provided  the  general  state  of  the  patient’s  health 
would  warrant  such  a proceeding.  In  some  of  the  cases  of  uterine  haemor- 
rhage the  necessity  for  using  the  lancet  is  as  great  as  that  which  exists  in 
haemoptce  or  other  arterial  haemorrhages.  But  it  will  be  his  duty  carefully 
to  discriminate  between  the  cases  from  nisus  and  those  simpler  effusions 
of  blood  that  proceed  from  an  accidental  detachment  of  a portion  of  the 
placenta,  in  which  the  blood  escapes  as  in  a wound,  and  not  by  a nisus 
haemorrhagicus . 

It  is  highly  expedient,  in  all  serious  cases  of  uterine  haemorrhage,  for 
the  attendant  to  demand  the  privilege  of  Touching,  without  which  I con- 
ceive it  impossible  for  him  to  enjoy  the  light  that  should  guide  his  ministry 
— but  let  him  not  resort  too  frequently  to  the  operation,  which  is  so  loudly 
condemned  by  Dr.  Dewees,  as  both  mischievous  and  useless ; let  him 
acquire  the  desirable  information  as  fully  and  completely  as  possible,  and 
rest  satisfied  with  that  until  some  evident  necessity  arises  for  a new 
research. 

A woman  flooding  should  be  kept  profoundly  still:  she  ought  not  to  be 
permitted  to  rise,  for  the  urine  or  stool — and  should  be  advised  to  move  her 
arms  and  lower  limbs  as  little  as  possible.  The  apartment  ought  to  be 
ventilated,  whether  in  winter  or  summer;  and  at  either  season,  I am  accus- 
tomed to  open  the  windows  and  doors  if  the  danger  be  imminent.  The  re- 
frigerant power  of  cloths  wrung  out  of  cold  spirit  and  water,  or  vinegar  and 
water,  is  to  be  availed  of.  Such  napkins,  not  dripping,  but  wrung  as  hard 
as  possible,  ought  to  be  applied  to  the  hypogastrium  and  thighs.  All 
exciting  conversation  should  be  suppressed  ; the  attendants  should  be  no 
more  numerous  than  necessary,  and  their  movements  ought  to  be  gentle 
and  considerate,  without  hurry  or  appearance  of  alarm. 

Fortunately,  in  most  cases,  where  the  extravasated  blood  is  allowed  to 
flow  freely  away,  not  being  checked  or  dammed  up  in  the  passage,  the 
flooding  mostly  ceases  as  soon  as  the  loss  has  been  sufficient  to  bring  on  a 
slight  feeling  of  faintness ; and  the  check  once  obtained,  the  loss  is  not 
renewed  if  the  woman  lies  perfectly  still;  but  is  very  apt  to  recommence, 
if  she  tosses  herself  too  much  on  the  bed. 

Styptic  medicines  are  of  very  little  avail  here.  Opium  is  of  very  great 
value,  and  may  be  given  in  full  doses;  but  it  should  never  be  forgotten, 
that  the  haemorrhage,  when  the  placenta  is  detached,  may  never  cease  until 
life  has  escaped  along  with  the  last  drops,  unless  the  uterine  cavity  be 
allowed  to  contract.  And  this  contraction  of  the  womb  is  what  we  can 
almost  always  command. 

If  the  membranes  are  as  yet  unruptured,  let  them  be  broken ; so  that, 
upon  the  escape  of  the  waters,  the  parietes  of  the  womb  may  become  con- 
densed ; in  doing  which,  the  bleeding  vessels  will  be  constringed,  or  even 


UTERINE  HEMORRHAGE. 


615 


effectually  closed  to  such  a degree  that  from  that  moment  all  danger  is  at 
an  end.  This  is  what  is  called  Louise  Bourgeois’s  method. 

Should  the  flooding,  however,  continue,  after  the  rupture  of  the  ovum 
and  the  discharge  of  the  waters,  to  such  a degree  as  to  endanger  the 
mother’s  safety,  the  time  will  have  arrived,  or  will  soon  be  at  hand,  to  place 
her  in  a state  of  complete  security,  by  emptying  the  womb — that  is,  by 
removing  the  child.  This  may  be  done  by  what  is  called  Puzos’  method, 
which  consists  in  turning  it  and  delivering  it  by  the  feet;  or,  if  the  occa- 
sion should  present,  by  Levret’s  method,  which  consists  in  delivery  by 
the  forceps.  As  soon  as  practicable  after  the  child  is  removed,  let  the 
placenta  be  taken  away,  when  no  obstacle  is  left  in  the  way  of  those 
effective  contractions,  by  which  the  uterine  tissue  is  entirely  condensed, 
its  arteries  compressed  in  every  dimension,  and  the  orifices  as  well  closed 
nearly  as  if  shut  by  the  ligature.  These  are  the  true  and  reliable  prin- 
ciples on  which  uterine  haemorrhage  ought  to  be  treated — it  being  under- 
stood to  be  the  province  of  the  physician,  and  his  alone,  to  decide  as  to  the 
time  and  method  of  acting.  To  trust  the  gravid  womb,  under  flooding,  to 
the  efficacy  of  a coagulum,  is  what  few  practitioners  of  experience  would 
approve.  They  all  know  that  the  cure  lies  in  a contracted  and  well  con- 
densed womb. 

It  frequently  happens,  that  when  a woman  has  been  well  and  safely 
delivered,  she  shall  have  the  uterus  well  contracted,  firm  and  small  in  the 
hypogastrium — and  expresses  herself  as  comfortable , but  within  an  hour, 
more  or  less,  she  shall  suddenly  faint  away,  and  be  without  pulse  or 
motion.  In  such  a case,  the  hand,  when  placed  upon  the  hypogaster,  finds 
the  womb  now  raised  up  almost  to  the  navel — or  it  may  be,  that  it  is  but 
slightly  enlarged  or  expanded  again. 

Such  an  occurrence  always  gives  rise  to  a panic  in  the  lying-in  room ; 
and,  indeed,  there  is  reason  to  fear  she  may  never  recover,  unless  proper 
measures  be  taken.  A direction  should  be  given  to  open  all  the  windows 
and  doors,  no  matter  what  may  be  the  state  of  the  weather.  The  bed 
clothes  should  be  lightened.  One  hand  should  be  pressed  upon  the  ex- 
panded uterus,  while,  without  moving  the  patient  and  with  the  least  possible 
delay,  the  other  should  be  gently  passed  upwards  into  the  vagina,  (the 
whole  hand,)  where  will  be  found  some  8 or  10  ounces  of  coagulated 
blood,  which  should  be  turned  out  by  a proper  motion  of  the  fingers — after 
which,  while  by  a reasonable  pressure  and  frictions  or  grasping  manoeuvre 
with  the  other  hand,  the  womb  is  pushed  downwards  into  the  strait,  the 
fingers — two  or  more  of  them — are  conducted  within  the  os  uteri ; there 
they  will  encounter  a very  firm  coagulum,  which  fills  and  distends  the 
womb.  This  clot  should  be  broken  up  by  the  points  of  the  fingers,  and 
turned  out  of  the  womb  into  the  vagina,  and  so  until  the  womb  is  ascer- 
tained to  be  empty  and  well  contracted.  When  the  womb'  and  vagina 
are  perfectly  freed  from  the  burden,  the  danger  is  over  for  the  present, 


616 


UTERINE  HAEMORRHAGE. 


and  the  success  ought  to  be  insured  by  means  of  a thick  compress  and 
binder  for  the  lower  belly. 

If  the  woman  be  weak,  some  wine,  some  brandy  and  water,  some  vola- 
tile alkali  or  other  convenient  cordial  ought  to  be  administered  at  once,  and 
a proper  nourishment  should  be  prepared  as  hastily  as  possible.  For  a 
great  many  years,  I have  had  the  custom  of  prescribing  for  women  very 
much  sunken  with  flooding,  a nutriment  prepared  as  follows  : — Take  a slice 
of  bread  cut  thin;  pare  off  the  crust;  then  lay  the  bread  in  a soup-plate, 
and  sprinkle  it  with  salt ; pour  upon  it  half  a pint  of  boiling  milk,  and  it  is 
ready  for  use.  I think  that  a few  spoonfuls  of  this  diet  will  afford  the 
lightest,  most  nutritious  and  speediest  preparation  that  can  be  got  for  such 
emergencies.  It  was  the  custom  of  Dr.  Clarke,  of  London,  to  make  use  of 
it,  and  I rarely  have  ordered  any  thing  else  under  such  circumstances  for 
many  years  past.  The  patient  likes  it,  and,  so  far  as  I know,  it  is  unob- 
jectionable in  every  respect. 

When  a patient  has  thus  been  rescued  from  visible  danger,  let  the  medical 
attendant  not  leave  her  bed-side  until  she  is  quite  safe — for  such  is  the  state 
of  the  womb  after  labour  in  some  women,  that  it  will  give  way  and  fill  two 
or  three  times ; for,  where  the  contractile  power  is  but  feeble,  the  blood  of 
the  lochia  coagulates  and  stops  the  mouth  of  the  womb  like  a tampon — 
whereupon  the  parietes  begin  to  yield,  and  the  more  the  vessels  bleed,  the 
more  rapidly  will  they  bleed,  until  the  cavity  becomes  enormously  dis- 
tended and  the  woman  faints  and  dies. 

I have  repeatedly  been  compelled  to  turn  out  the  clots  as  much  as  three 
times  in  the  same  patient.  If  one  were  very  watchful,  he  should  not  permit 
the  coagulum  to  be  formed. 

The  nurses,  when  they  give  a napkinto  the  patient,  should  tell  her  that 
the  cloth  is  for  receiving  the  discharge  and  not  for  the  purpose  of  stopping 
it,  and  that  it  should  not  be  jammed  close  to  the  genitalia.  When  the  nap- 
kins are  packed  close  up  to  the  patient’s  person,  they  act  as  a tampon  does ; 
they  stop  the  blood  in  the  vagina,  which  first  fills,  and  then  backs  it  into 
the  womb. 

Where  the  case  has  a critical  appearance,  the  surgeon’s  hand  should  be 
insinuated  beneath  the  compress  and  binder,  so  as  to  enable  him  to  touch 
the  uterine  globe,  and  irritate  it  by  pressure  and  friction,  or,  at  least,  inform 
himself  of  its  actual  state  and  disposition.  I have  thought  fit  to  offer  these 
remarks  as  supplementary  to  those  of  the  author,  which  I deem  to  be  less 
copious  than  is  demanded  by  the  importance  of  the  subject. — M.] 

OF  HAEMOPTYSIS,  H.EMATEMESIS  AND  EPISTAXIS. 

Haemoptysis,  or  spitting  of  blood,  is  one  of  the  most  dangerous 
complications  of  the  pregnant  state.  This  haemorrhage,  which 
escapes  from  the  lungs  during  more  or  less  frequent  paroxysms  of 


HAEMOPTYSIS,  HiEMATEMESIS,  EPISTAXIS. 


617 


cough,  is  met  with  particularly  in  women  of  sanguine  or  nervous 
temperament,  and  in  those  who  wear  very  tight  clothing.  The 
exciting  causes  of  the  affection  in  pregnant  women,  are  all  con- 
nected with  their  condition,  because  the  uterus  becomes  more  volu- 
minous, and,  pressing  upwards  the  abdominal  viscera  and  diaphragm, 
diminishes  the  capacity  of  the  thorax,  whence  follow  first  embarrass- 
ment of  the  pulmonary  circulation,  and  then  a cough  and  rupture  of 
some  of  the  bronchial  vessels. 

The  prodromes  of  the  affection  are  dry  cough  and  sensation  of 
heat  in  the  chest,  which  commonly  appear  towards  the  fourth  and 
fifth  month.  There  are  felt  praecordial  anxiety,  pains  about  the  dia- 
phragm, accompanied  by  horripilation  and  coldness  of  the  extremities. 
Finally,  respiration  becomes  difficult,  expectoration  of  bloody  and 
frothy  sputa  appears,  particularly  after  eating,  and  is  increased  by 
exercise,  by  remaining  in  too  warm  an  atmosphere  or  in  a very  warm 
bed,  and  by  all  circumstances  capable  of  exciting  the  circulation. 

The  prognosis  of  the  affection  is  always  unfavourable  during  preg- 
nancy, when  before  conception,  there  had  been  disposition  to  cough, 
pain  between  the  shoulders,  and  especially  when  the  patient  has  a 
narrow  chest,  projecting  cheek-bones,  hollow  temples,  and  a weak, 
feeble  constitution.  In  some  of  the  cases,  however,  haemoptysis  is 
attended  with  but  little  danger ; such  is  that  in  which  it  is  the  result 
of  a slight  sanguine  exhalation  from  the  bronchial  mucous  membrane, 
produced  by  some  disorder  of  the  pulmonary  circulation,  or  by  an 
engorgement  or  any  kind  of  obstacle  to  the  passage  of  the  blood. 
Under  these  circumstances,  the  sanguinolent  sputa,  which  occur  with- 
out effort  or  fever,  are  small  in  quantity,  do  not  reappear,  and  almost 
always  yield  to  a small  bleeding. 

To  avoid  confounding  haemoptysis  with  haematemesis  or  vomiting 
of  blood,  to  which  pregnant  women  are  much  less  subject,  we  need 
only  recollect  that  in  the  latter  haemorrhage,  the  blood  which  comes 
from  the  stomach  is  black,  grumous,  often  mixed  with  the  food, 
mucosities  or  bile,  and  generally  expelled  without  cough.  The  blood 
which  escapes  from  the  lungs  is,  on  the  contrary,  vermilion  in  colour, 
frothy  and  without  mixture  with  other  fluid,  and  escapes  generally 
in  a paroxysm  of  coughing ; it  is  important,  moreover,  to  ascertain 
whether  the  effusion  may  not  depend  upon  pneumonia  or  some  dis- 
ease of  the  heart. 

The  treatment  of  the  affection  consists  first  in  the  employment  of 
bleeding,  to  relieve  the  local  plethora;  and  then  in  calming  the  irri- 
tation of  the  lungs  by  opiates  and  antispasmodics,  amongst  others 
the  infusions  of  orange  and  linden  flowers,  sweetened  with  syrup  of 
poppies.  To  these  means  may  be  added  derivatives  to  the  limbs 
and  digestive  canal,  bechic  and  astringent  drinks,  strict  diet,  and 
quiet  of  mind  and  body ; lastly,  in  some  cases,  we  may  have  resort 
to  cold  applications  about  the  chest,  and  to  iced  mineral  lemon- 
ade. We  will  add  that  the  treatment  of  hsematemesis  is  the  same 
as  that  of  haemoptysis,  except  in  case  an  attack  of  colic,  which  the 
patient  sometimes  experiences,  makes  us  suppose  that  there  are  accu- 


618 


EPISTAXIS;  PLETHORA. 


mulations  of  blood  in  the  intestines,  when  its  escape  may  be  assisted 
by  means  of  emollient  enemata  and  light  laxatives. 

Epistaxis,  or  nasal  haemorrhage,  occurs  in  pregnant  women  more 
frequently  even  than  haemoptysis  and  hsematemesis ; but  this  haemor- 
rhage, whose  return  can  seldom  be  prevented  by  bleeding,  ought  to 
be  regarded  rather  as  a useful  evacuation  than  as  a real  diseaes. 
For  this  reason,  its  prognosis  is  much  less  unfavourable  than  that  of 
the  preceding  diseases,  though  like  them,  it  is  generally  the  result  of 
plethora  or  of  obstruction  of  the  pulmonary  circulation.  In  general, 
the  haemorrage  is  left  to  itself,  when  slight,  but  should  the  discharge 
become  too  frequent  or  too  abundant,  it  is  proper  to  arrest  it,  by 
placing  the  patient  in  a cool  air,  and  by  keeping  the  head  elevated 
and  covered  with  compresses,  wet  with  cold  vinegar  or  sulphuric 
ether.  If  these  means  are  insufficient,  we  must  resort  to  bleeding, 
to  mustard  manuluvia,  and  even  to  plugging  the  nasal  fossa.  We 
ought  to  remark  that  there  is  a means  that  has  succeeded  in  our 
hands  in  a number  of  cases,  which  consists  in  keeping  the  arms  ele- 
vated, and  in  the  application  of  a cold  body  between  the  shoulders. 

DISORDERS  OF  THE  CIRCULATION  DURING  PREGNANCY. 

Of  Sanguine  Plethora. 

The  physiological  changes  that  take  place  in  pregnancy  very  well 
explain  the  derangements  of  the  circulation  which  accompany  that 
condition.  Some  physicians  have  supposed  plethora  to  be  almost 
the  sole  cause  of  the  diseases  of  pregnant  women ; this  opinion,  be- 
come at  last  a vulgar  one,  is  true,  particularly  for  the  haemorrhages 
of  which  we  have  just  spoken,  and  for  other  lesions  of  the  circulation 
of  which  we  are  about  to  treat. 

Plethora , or  anormal  increase  of  blood,  occurs  mostly  in  women 
of  strong  and  sanguine  constitution,  and  particularly  in  those  who 
were  abundantly  regulated  before  pregnancy.  The  causes  which 
concur  to  produce  plethora  are,  independent  of  the  menstrual  flux, 
the  increased  activity  of  nutrition  during  gestation,  and  often  a want 
of  exercise  and  food  of  too  succulent  a character. 

The  phenomena  which  reveal  the  state  of  predominance  of  blood 
in  pregnant  women  are  fulness  and  hardness  of  the  pulse,  and  a sen- 
sation of  swelling  in  the  limbs,  which  interferes  with  their  move- 
ments. The  surface  is  warm  and  highly  coloured ; there  is  a taste 
of  blood  in  the  mouth ; the  gums  are  painful ; the  eyes,  lips  and  nos- 
trils are  red  and  injected ; the  veins  are  swollen  and  projecting ; the 
head  is  heavy,  with  disposition  to  sleep ; there  are  tinnitus  aurium, 
giddiness,  epistaxis,  and  signs  of  congestion  about  the  pelvic  region. 

Though  the  symptoms  of  plethora  may  show  themselves  at  any 
period  of  pregnancy,  it  is  generally  towards  the  sixth  or  seventh 
month  that  they  are  most  marked.  In  some  cases,  though  always 
inconvenient  and  even  insupportable,  they  may  exist  for  a long  time 
without  greatly  deranging  the  health  ; but  there  occur  haemorrhages 
which  sometimes  produce  the  most  dangerous  consequences. 


PLETHORA,  PALPITATION. 


619 


The  prophylactic  and  therapeutical  treatment  of  plethora  consists 
in  the  use  of  a regimen  containing  but  little  nourishment,  and  com- 
posed principally  of  vegetables ; in  diluent  drinks,  emollient  enemata, 
laxatives,  moderate  exercise,  and  especially  in  the  employment  of 
bleeding.  The  period  of  the  pregnancy  at  which  blood  ought  to  be 
taken  cannot  be  determined;  in  general,  bleeding  should  be  em- 
ployed when  it  is  necessary,  and  only  then.  The  quantity  of  blood 
must  be  sufficient  to  remove  the  plethoric  condition,  and  never  so 
copious  as  to  enfeeble  the  patient.  We  ought  to  remark,  however, 
that  a great  many  physicians  are  in  the  habit  of  bleeding  in  all  cases 
between  the  fourth  and  fifth  months  of  the  pregnancy.  This  method, 
which  is  good  in  some  cases,  is  irrational  and  injurious  in  many 
others.  We  should  abstain  from  bleeding  when  the  women  expe- 
rience slight  symptoms  merely  of  increased  activity  of  hsematosis. 

OF  PALPITATION. 

In  the  pregnant  state,  the  heart  is  sometimes  agitated  with  palpi- 
tations, that  is  to  say,  with  tumultuous  movements  and  with  stronger 
impulse  than  ordinary.  Nervous  women  are  more  subject  to  them 
than  others;  yet  those  of  robust  and  plethoric  temperament  are  like- 
wise exposed  to  them ; but  in  this  condition  the  disordered  action 
of  the  heart  is  the  result  of  plethora.  The  affection  is  recognized  by 
the  violence  and  irregularity  of  the  pulsations  of  the  heart,  which 
are  sometimes  so  strong  as  to  arouse  the  patients  suddenly  from  sleep. 
The  heart,  which  strikes  against  the  parietes  of  the  thorax  with  great 
force,  suspends  its  palpitations  at  irregular  intervals,  and  follows  the 
movements  of  the  pulse,  which  are  unequal  and  intermittent. 

The  cause  of  the  palpitations  depends  generally  upon  a nervous 
condition  and  sympathetic  irritation  of  the  uterus;  it  may  be  con- 
nected also  with  plethora,  and  in  some  cases,  perhaps,  with  the  pres- 
sure exerted  upon  the  abdominal  vessels  by  the  gestative  organ 
whose  volume  is  much  increased.  We  must  confess,  however,  that 
the  intermissions  of  the  symptoms  and  their  disappearance,  or  at 
least  diminution,  towards  the  approach  of  labour,  when  the  womb 
has  acquired  a greater  development,  should  throw  some  doubts  upon 
the  last  cause  we  mentioned. 

In  general,  the  palpitations  of  pregnant  women  constitute  less  a 
disease  than  a painful  and  troublesome  inconvenience,  from  which 
they  ought  to  be  relieved. 

When  the  affection  is  of  a nervous  character,  it  is  treated  by  anti- 
spasmodics,  opium,  ether,  assafoetida,  syrup  of  asparagus  shoots, 
cherry-laurel  water,  tincture  or  powder  of  digitalis,  syrup  of  lactuca- 
rium,  and  lastly,  by  the  medicinal  prussic  acid,  and  even  by  bleeding. 
To  these  means  are  added  baths,  demulcent  enemata,  and  moderate 
exercise  in  the  open  air.  If  the  disorder  of  the  circulation  occurs  in 
a strong  and  sanguine  female,  and  seems  to  be  connected  with  ple- 
thora, it  is  to  be  treated  by  bleeding  and  suitable  regimen.  Care 
should  be  taken,  moreover,  to  advise  the  patient  to  sleep  with  the 


620 


PALPITATION. 


head  elevated,  to  eat  moderately,  especially  at  night,  and  to  abstain 
from  wine,  coffee,  liquors  and  all  exciting  articles. 

[In  a note  at  page  608,  I have  expressed  an  opinion  as  to  the  im- 
portance of  making  out  a correct  diagnosis  of  the  cases  of  palpitation,  and 
have  said  that  pregnancy  is  for  some  constitutions  a cause  of  anaemia.  Let 
a careful  discrimination  be  made,  then,  between  the  cases  of  palpitation 
arising  from  slow  inflammation  of  the  pericardium,  and  such  as  spring  from 
a similar  affection  of  the  endocardium,  and  those  that  proceed  from  an  anae- 
mic state.  The  latter  are  exceedingly  distressing  and  dangerous,  yet 
not  so  much  so  as  the  former,  for  they  recover  after  the  termination  of  the 
pregnancy,  while  the  former  are  often  followed  by  violent  aggravation  of 
the  distress  in  the  post-puerperal  condition.  Where  the  endocarditis  exists 
during  the  labour,  the  process  of  parturition,  which  generally,  and  in  this 
case  almost  inevitably,  provokes  a high  degree  of  vascular  excitement,  is 
sure  to  aggravate  the  malady  of  the  heart,  and  we  have  then  the  most  fright- 
ful hurry  and  irregularity  of  the  pulse; — but  such  a state  of  disorder  of  the 
vascular  circulation  is  to  the  last  degree  hazardous  for  the  puerperal  or 
lying-in  woman.  I have  had  occasion  to  observe  not  a few  such  instances. 
In  one  of  them,  the  lady,  who  had  long  been  subject  to  disorder  arising  from 
attacks  of  endocarditis,  got  very  well  through  her  labour,  and  continued  to  be 
pretty  well  for  three  or  four  days — when  she  was  suddenly  seized  after 
breakfast  with  palpitation  of  the  heart,  which  soon  made  her  feel  and  look 
so  ill  that  1 was  sent  for.  I found  her  pale  and  feeble,  and  without  power 
to  move,  for  upon  the  least  attempt  to  change  her  position,  (she  was  lying 
on  the  back,)  she  appeared  ready  to  expire.  I could  by  no  means  count 
the  pulse;  it  was  so  rapid  as  to  go  far  beyond  my  power  to  count  it  by  the 
second-hand  of  my  watch.  I can  with  considerable  accuracy  count  the 
pulse  at  180  in  the  minute — and  I judged,  after  much  reflection,  that  the 
heart  beat  at  least  240  strokes  per  minute.  Thus  it  continued  to  do  from 
half-past  eight  in  the  morning  until  near  eight  in  the  evening — more  than 
eleven  hours.  Now  her  pulse  ought  to  have  amounted  to  46,200  pulsations 
of  the  heart  in  the  eleven  hours,  but  the  real  number  of  beats  was  158,400, 
which  is  112,200  beats  more  than  natural — more  than  are  required  for  the 
wants  of  the  healthy  constitution.  It  is  easier  to  imagine  than  to  describe 
the  frightful  fatigue  of  this  lady  during  all  those  eleven  hours — in  which 
death  seemed  to  be  close  at  hand,  for  there  was  the  greatest  probability  that 
the  heart  would  cease  to  beat  altogether,  unless  some  measures  could  be 
adopted  to  arrest  its  wild  career.  There  was  no  extra  heat  of  the  body — 
no  delirium — but,  on  the  contrary,  the  temperature  was  nearly  natural,  and 
the  mind  calm — the  countenance  clothed  with  a melancholy  and  distressed 
expression,  which  excited  the  greatest  sympathy  of  the  beholders.  The 
respiration  was  quick  and  very  short.  The  impulse  of  the  heart  upon  aus- 
cultation was  neat  and  clear,  and  there  was  not  the  least  intercurrence  of 


PALPITATION. 


621 


the  first  and  second  sounds.  I was  convinced  that  no  effusion  existed — her 
complaint,  in  a scarce  audible  voice,  was  of  excessive  fatigue  about  the 
breast,  and  the  greatest  debility.  My  desire  was  to  take  blood  from  the 
arm,  supposing  that  I might  thus  affect  the  sources  of  her  innervation,  so  as 
to  arrest  the  flight  of  the  pulse.  All  the  other  remedies,  in  the  shape  of 
antispasmodics,  counter-irritants,  &c.,  &c.,  which  I persevered  to  apply, 
completely  failed  ; and  such  was  the  condition  of  the  circulation  that  I could 
not  venture  to  open  a vessel  in  the  arm,  for  1 felt  sure  that  a fainting  fit 
would  terminate  her  existence.  The  heart  was  so  exhausted,  that  had  she 
fainted  badly,  I conceived  nothing  would  be  able  to  restore  its  full  motion 
again.  Near  eight  o’clock  in  the  evening,  I told  her  friends  that  I should 
open  the  vein,  but  under  the  greatest  apprehension  she  might  faint  and  die, 
but  convinced  of  the  necessity  of  doing  it  in  order  to  prevent  an  otherwise 
fatal  termination.  I accordingly  had  a strong  light  thrown  upon  her  face, 
in  order  to  be  able  to  detect  the  first  symptoms  of  a change  in  the  innerva- 
tion about  to  be  produced — I being  quite  sure,  that  under  the  circumstances, 
the  pulse  would  not  be  a safe  guide,  for  I expected  that  when  it  should  fall, 
it  would  give  way  instantly.  The  vein  bled  well,  and  I had  not  to  take 
more  than  four  ounces  before  I discovered  a change  of  the  expression  about 
the  mouth,  when  she  admitted  also  that  she  was  a little  sick.  Upon  binding 
up  the  arm,  I took  the  wrist,  and  found  the  rapidity  undiminished.  'While 
feeling  the  pulse,  it  suddenly  stopped,  and  the  head  was  rotated  to  the  right 
side,  as  if  in  spasm  ; she  uttered  a prolonged  groan,  and  I supposed  her 
dead  ; but,  after  a suspension  of  several  seconds,  the  heart  resumed  its  rapid 
flight  for  some  ten  or  twenty  seconds,  then  stopped  again,  so  long  that  I 
thought  it  would  never  beat — it  then  fluttered  for  a moment — and  from  that 
moment  her  pulse  was  as  gentle,  and  regular,  and  orderly  as  if  in  the  finest 
health.  She  recovered  afterwards,  having  subsequently  complained  only  of 
debility.  During  these  eleven  hours  I scarcely  left  her  bed-side,  and  have 
not  had,  in  a long  course  of  practice,  occasion  to  pass  a day  of  more  thrilling 
interest  in  relation  to  one  to  whom  I had  no  ties  other  than  those  of  the 
medical  adviser  to  his  patient.  Nor  can  I now  well  conceive  of  a case  more 
exciting  than  one  in  which  an  organ,  the  very  centre  and  source  of  motion 
and  life,  was  in  so  extraordinary  a predicament.  Let  the  reader  imagine  the 
organic  fatigue,  if  such  an  expression  be  allowable,  which  the  heart  must 
have  endured,  under  112,200  extra-pulsations  in  that  space  of  time. — M.] 

OF  SYNCOPE. 

If  inordinate  contractions  of  the  heart  constitute  one  of  the  acci- 
dents of  the  pregnant  state,  the  same  is  true  of  the  suspension  of 
the  contractions  of  the  organ,  which  may,  in  pregnant  women,  occa- 
sion syncope : this  condition  consists  in  a complete  and  generally 
sudden  loss  of  sensation  and  motion,  with  suspension  of  respiration. 
This  sort  of  temporary  death,  which  generally  lasts  only  four  or  five 


622 


SYNCOPE,  VARIX. 


minutes,  recurs  periodically  in  certain  women,  once  a month,  once  a 
week,  once  in  every  two  or  three  days,  and  even  oftener.  During 
the  attack  the  countenance  and  skin,  as  well  as  the  adnata  of  the 
eyes,  the  lips  and  mouth,  lose  their  colour,  and  resemble  the  paleness 
of  death ; the  senses  are  paralyzed,  ( suspended , M.,)  the  sensations 
nullified,  and  there  is  a complete  loss  of  consciousness.  The  attacks 
come  on  with  yawning,  tinnitus  of  the  ears,  and  a dull  pain  at 
the  epigastrium;  they  terminate  by  an  insensible  return  of  the 
respiration  and  pulse,  and  frequently  by  throwing  up  the  contents  of 
the  stomach. 

The  predisponent  causes  of  syncope  in  pregnant  women  depend 
on  a disturbing  force,  connected  with  the  pregnant  state,  which 
influences  all  the  functions  of  the  body.  The  determining  causes 
are  sometimes  found  to  be  the  sudden  brisk  motions  of  the  foetus,  a 
vertical  posture,  a kneeling  posture,  particularly  one  long  continued, 
the  sight  of  certain  objects,  strong  emotions,  a sudden  sound,  the 
odour  of  certain  sorts  of  plants,  or  certain  substances;  and,  lastly,  a 
state  of  plethora  or  one  of  anaemia,  may  likewise  bring  on  attacks  of 
syncope  in  pregnant  women. 

Syncope  is  generally  a more  serious  affair  as  regards  the  foetus 
than  as  regards  the  mother,  whose  life  is  less  endangered  by  a some- 
what protracted  fainting  fit  than  is  that  of  the  infant. 

The  treatment  of  this  accident  of  pregnancy  consists  in  recalling 
the  functions  of  life,  chiefly  those  of  the  respiration  and  circulation. 
We  generally  succeed  very  readily  in  effecting  this  result  by  placing 
the  woman  in  a horizontal  position,  by  relieving  her  of  those  parts 
of  her  dress  that  might  obstruct  the  motions  of  her  breast,  abdo- 
men, neck  and  limbs ; by  making  her  inhale  strong  odours,  such  as 
the  odour  of  liquid  ammonia,  pure  acetic  acid,  or  burnt  feathers, 
and,  further,  by  making  frictions  on  the  region  of  the  heart,  either 
dry  or  with  cloths  wrung  out  of  brandy,  or  cologne  or  balm  water. 
Care  should  likewise  be  taken  to  expose  her  to  fresh  air,  to  sprinkle 
cold  water  on  the  face,  and  to  apply  sinapisms  to  the  arms  and  legs, 
which  may  also  be  wrapped  in  cloths  wrung  out  of  very  warm 
water.  When  the  patient  recovers  her  consciousness,  she  should 
swallow  a portion  of  Garus’s  Elixir,  or  a little  wine,  or  any  other 
alcoholic  liquor  diluted  with  water. 

For  the  purpose  of  preventing  as  far  as  possible  a return  of  the 
attack,  the  woman,  if  plethoric,  should  be  bled,  take  moderate  exer- 
cise, and  make  use  of  some  sort  of  antispasmodic  medicine. 

OF  VARICES. 

Among  the  complications  of  pregnancy  none  is  met  with  more 
frequently  than  a varicose  state  of  the  veins.  For  the  most  part, 
they  begin  to  grow  towards  the  close  of  the  pregnancy,  and  affect 
most  especially  the  lower  extremities,  and  particularly  the  saphena 
vein;  they  are,  however, found  to  invade  all  the  superficial  branches 
of  the  legs  and  thighs,  the  labia,  vagina  and  cervix  uteri.  Pregnant 
women  have  been  seen  even,  in  whom  all  the  veins  were  swollen 


VARICOSE  VEINS. 


623 


and  knotty  without  excepting  even  those  of  the  upper  extremities, 
exhibiting,  indeed,  a general  varicose  diathesis.  We  should  remark, 
however,  that  it  mostly  happens  that  one  side  is  more  affected  than 
the  other,  probably  because  the  womb  presses  most  upon  that  side. 

Wherever  they  happen  to  be  formed,  these  varices  appear  under 
the  form  of  small  lumps,  like  a string  of  beads,  or  like  a bunch  of 
leeches  twisted  together,  or  they  look  like  oblong,  round,  uneven, 
indolent  knots,  which  generally  disappear  under  pressure,  and  return 
upon  withdrawing  the  pressure,  diminishing  by  rest  in  bed,  and 
increasing  upon  resuming  a vertical  posture : they  are  without  any 
pulsation,  and  generally  exhibit  a sort  of  arborescent  appearance. 

Although  the  rupture  of  a small  varix  is,  in  most  cases,  a slight 
accident,  readily  cured  by  compression,  it  does  happen  that  such  an 
accident  becomes  promptly  fatal,  especially  where  there  is  a varicose 
diathesis,  and  where  the  rupture  occurs  in  a large  vessel,  such  as  the 
internal  iliac  or  superior  cava. 

The  causes  of  this  dilatation  of  the  veins  may  depend  upon  a 
natural  or  accidental  weakness  of  the  vessels,  and  a certain  disposi- 
tion in  them  to  allow  themselves  to  be  easily  distended  with  the 
blood,  whose  circulation  is  obstructed  by  the  pressure  of  the  womb 
upon  the  iliac  veins. 

In  order  to  prevent  this  unmeasured  distension  of  the  veins,  and 
the  rupture  of  the  tumour  thus  formed,  we  should  recommend  the 
patient  to  keep  a soluble  state  of  the  bowels ; a horizontal  posture, 
rest,  and,  lastly,  compression  of  the  limbs  by  means  of  the  roller 
or  a laced  stocking,  which  should  be  applied  in  the  morning  before 
rising  from  bed,  because  the  veins  are  then  less  distended  with  blood. 
In  plethoric  women  bleeding  is  one  of  the  useful  remedies  to  which 
recourse  ought  to  be  had.  The  resources  of  surgery  have  never  been 
emyloyed  in  varix  in  the  pregnant  female,  for  they  always  disappear 
after  the  lying-in,  except  in  cases  where  they  have  been  renewed  by 
numerous  and  rapidly  succeeding  pregnancies. 

Varices  of  the  cervix  uteri  may  interfere  with  labour,  as  they  are 
liable  to  burst  during  the  throes,  and  give  rise  to  a considerable 
haemorrhage.  We  should  endeavour  to  prevent  their  rupture  by  sus- 
taining and  gently  repressing  them  with  the  ends  of  the  fingers.  In 
case,  notwithstanding  these  precautions,  one  of  the  varices  should 
give  way,  we  ought  to  tampon  the  orifice  of  it  with  linen  soaked  in 
alum  water  or  any  other  suitable  styptic  liquor. 

[M.  Colombat  has  omitted  to  notice  an  important  item  in  the  consider- 
ation of  the  varices  of  pregnant  women.  They  are  often,  it  is  true,  only 
troublesome  during  the  pregnancy,  and  that  evil  may  be,  in  general,  very 
readily  obviated  by  the  use  of  the  roller  and  the  other  measures  recom- 
mended by  the  author. 

I fear,  however,  that  an  insufficient  degree  of  attention  is  paid  to  the  more 
severe  and  extensive  samples  of  varix,  both  by  the  patient  and  the  physi- 
cian. In  some  such  instances  I have  had  to  contend  with  dangerous  crural 
phlebitis  coming  on  after  labour,  and  clearly  taking  its  rise  in  the  already  dis- 


624 


HEMORRHOIDS. 


eased  and  distended  state  of  the  veins  of  the  leg;  and  I had  the  misfortune, 
about  two  years  since,  to  witness  the  loss  of  one  of  my  patients,  in  whom 
the  enormous  varicose  veins  of  the  right  leg  and  thigh  were  attacked,  after 
her  confinement,  with  phlebitis  terminating  in  the  production  of  pus  and  all 
the  distressing  consequences  of  the  pyogenic  fever.  I merely  desire,  at  this 
point,  to  call  the  attention  of  the  reader  to  the  propriety  of  taking  all  due 
precautions  against  the  development  of  that  dangerous  malady,  after  the 
delivery  of  the  patient,  who  is  so  unfortunate  as  to  have  very  bad  varices  of 
the  legs. — M.] 


OF  HAEMORRHOIDS. 

The  occurrence  of  haemorrhoids  in  the  pregnant  woman  has  gene- 
rally been  assigned  to  the  same  causes  that  give  rise  to  varix  of  the 
lower  extremities.  It  is  at  least  certain  that  costiveness,  to  which 
women  with  child  are  very  subject,  is  one  of  the  most  common  and 
undeniable  causes  of  piles.  We  may,  also,  it  is  true,  depend  on  the 
volume  of  the  womb,  whose  pressure  upon  the  veins  within  the 
pelvis,  obstructs  the  circulation  and  provokes  an  engorgement  of  the 
hssmorrhoidal  vessels.  Be  this  as  it  may,  the  disorder  in  question 
may  be  met  with  at  any  period  of  gestation,  rarely  in  the  early 
months,  more  frequently  towards  the  middle,  and  still  more  fre- 
quently near  the  term,  especially  in  women  of  a costive  habit. 

Where  the  hsemorrhoidal  tumours  are  indolent,  and  not  very 
painful,  they  constitute  a mere  inconvenience,  which  the  female 
submits  to  in  silence  without  consulting  her  physician ; but  in  cer- 
tain cases  they  cause  an  active  inflammation,  with  very  acute  pains, 
a great  obstruction ; inability  to  sit,  tenesmus,  fruitless  efforts  at  stool, 
and,  in  some  instances,  even  a prolapsus  of  the  rectum;  inflam- 
mation, suppuration  and  ulceration  of  the  hasmorrhoidal  mass ; and 
even  uterine  contraction  and  abortion.  To  these  symptoms  should 
be  added  dyspnoea,  insomnia,  restlessness,  headache  and  a fever  of 
greater  or  less  violence. 

From  the  above  sketch,  it  may  be  perceived  that  the  consequences 
of  haemorrhoidal  attacks  may  be  very  serious;  yet  these  tumours  do 
not,  in  general,  prove  injurious  in  pregnancy,  particularly  if  they 
bleed,  and  the  bleeding  be  not  too  profuse.  On  the  other  hand, 
where  the  loss  of  blood  is  abundant  and  long-continued,  exhaus- 
tion of  the  mother  and  the  death  of  the  child  may  be  the  con- 
sequences. 

Where  the  hsemorrhoidal  tumours  are  red,  tense,  painful  and  in- 
flamed, it  is  customary  to  order  the  bath ; emollient  and  narcotic 
fomentations ; oleaginous  injections,  suppositories  of  beurre  de  cacao , 
opiated  cerate,  unguent,  populeum,  a cooling  regimen,  and  bleeding  at 
the  arm,  where  the  woman  is  plethoric,  and  the  turgescence  and  pain 
considerable.  When  the  piles  are  internal  ones  and  inflamed,  warm 
milk,  with  a few  drops  of  laudanum,  may  be  injected  into  the  rec- 
tum ; and  the  bowels  can  be  kept  free  by  gentle  laxatives  and  emol- 


CEDEiMA. 


625 


Jient  enemata.  Should  the  hemorrhoidal  tumours  bleed  moderately, 
the  discharge  ought  not  to  be  interfered  with;  but  in  case  it  should 
become  too  profuse,  we  ought  to  endeavour  to  arrest,  or  at  least  to 
moderate  it  by  using  astringent  fomentations,  made  with  decoction  of 
pomegranate  rind,  bistort  root  or  nut-galls,  to  which  is  added  a little 
alum  or  sugar  of  lead  : in  fine,  for  the  more  serious  cases  the  rectum 
may  be  plugged  with  a roll  of  linen,  introduced  into  the  bowel.  ]t 
should  be  remembered,  however,  that  the  presence  of  the  tampon, 
which  is  always  distressing,  may  provoke  the  womb  to  abortion; 
and  that  the  measure,  which  is  never  to  be  resorted  to  but  in  extreme 
cases,  might  allow  an  accumulation  of  blood  to  take  place  within 
the  bowel,  and  thus  fail  of  arresting  an  internal  haemorrhage,  which, 
although  it  no  longer  appears  to  be  discharged  from  the  bowel, 
might  still  prove  sufficiently  profuse  to  deprive  the  patient  of  life. 

OF  (EDEMA. 

Most  of  the  modern  medical  authorities  attribute  the  oedema  of 
pregnant  women  to  a fault  of  the  venous  and  lymphatic  systems;  we, 
also,  have  not  hesitated  to  class  it  among  those  lesions  of  the  cir- 
culatory apparatus  that  are  dependent  upon  pressure  on  the  ves- 
sels. Indeed,  it  is  observed  that  the  disorder  under  consideration  is 
mostly  found  to  occur  in  the  latter  stages  of  pregnancy,  that  is  to 
say,  at  a time  when  the  volume  of  the  womb  is  greatest ; that  it 
generally  affects  the  lower  extremities,  especially  in  true  pregnancies; 
and  farther,  that  it  diminishes  while  the  woman  maintains  a recum- 
bent posture,  and  increases  by  standing  up  or  walking.  Be  this  as 
it  may,  women  of  a feeble  and  lymphatic  habit  of  body,  those 
whose  vascular  system  has  little  vigour,  or  who  have  a narrow  pelvis, 
are  most  exposed  to  attacks  of  oedema  of  the  lower  limbs,  a disorder 
which  first  manifests  itself  in  the  feet  and  legs,  and  then  extends 
upwards  on  the  thighs,  and  even  to  the  vulva,  the  groins  and  the 
parietes  of  the  abdomen. 

(Edema  sometimes  consists  in  a diffuse  indolent  whitish  swelling, 
which  pits  upon  pressure,  increases  towards  night  and  diminishes 
towards  morning ; sometimes,  again,  it  is  a more  or  less  extensive 
engorgement,  accompanied  with  pain,  heat,  and,  occasionally,  red- 
ness, and  a sort  of  elasticity  which  prevents  it  from  retaining  the 
impression  of  the  finger,  or  pitting. 

(Edema,  arising  from  a state  of  pregnancy,  is  mostly  not  at  all 
dangerous,  and  disappears  spontaneously  after  the  lying-in.  Where 
it  is  not  extensive,  it  gives  rise  merely  to  an  uneasy  sensation  and  a 
troublesome  feeling  of  weight.  W~hen  it  extends  to  the  thighs  and 
genitalia,  it  not  only  interferes  with  walking  and  sitting  down,  and 
occasions  much  pain  and  uneasiness,  but  when  the  skin  becomes 
excessively  distended,  it  is  liable  to  inflame  and  be  covered  with  ery- 
sipelatous patches.  Cases,  indeed,  have  been  met  with,  where  the 
subcutaneous  cellular  tela  has  been  affected  with  inflammation  ter- 
minating in  gangrene  of  the  skin.  Moreover,  a simple  cedematous 
swelling  may  become  sufficiently  extensive  to  obstruct  the  move- 
40 


626 


(EDEMA. 


merits  of  the  body,  interfere  with  the  respiration,  and  even  offer 
serious  obstacles  in  labour.  It  ought,  however,  to  be  understood 
that  oedema,  how  considerable  soever  it  may  become,  is  generally  not 
a serious  affection  for  pregnant  women.  Delamotte  assures  us  that 
he  never  saw  a female  perish  from  these  swellings,  even  the  most 
extensive  of  them,  and  that  those  who  do  suffer  from  them  are  ordi- 
narily not  troubled  with  vomiting. 

[It  may  be  very  true  that  Delamotte  did  not  see  fatalities  as  a direct  result 
of  oedema  gravidarum,  but,  in  his  great  experience,  it  is  probable  that  not  a 
few  cases  of  severe  malady,  such  as  eclampsia,  for  example,  might  have  been 
more  or  less  intimately  connected  with  oedema  of  the  limbs. — M.] 

Should  the  oedema  be  accompanied  with  symptoms  of  plethora, 
and  the  tumefaction  be  red  and  elastic,  venesection  is  the  most  appro- 
priate remedy,  and  should  be  prescribed  conjointly  with  mild  purga- 
tive and  diuretic  medicines,  which  alone  ought  to  be  ordered  when 
no  plethora  exists,  and  where  the  oedema  consists  in  a mere  infiltra- 
tion of  serosity  into  the  cellular  tela.  In  such  circumstances  we 
might  also,  with  propriety,  advise  the  patient  to  use  dry  friction, 
aromatic  lotions,  a gentle  compression  by  a roller  bandage,  and  the 
maintenance  of  a horizontal  posture.  Should  this  situation,  however, 
give  rise  to  a considerable  degree  of  oppression,  it  would  be  better 
for  the  patient  to  remain  seated  in  an  arm  chair,  and  especially 
on  a sofa.  In  fine,  should  these  proceedings  prove  to  be  inefficacious, 
and  the  swelling  become  very  extensive,  slight  punctures  may  be 
made  with  the  point  of  a lancet,  in  the  legs,  and  then  followed  by  a 
blister  applied,  according  to  Levret’s  advice,  on  the  space  betwixt  the 
thigh  and  the  labium  pudendi.  In  all  cases,  the  bowels  should  be 
kept  soluble,  by  injections  and  gentle  purgatives ; the  dresses  should 
be  warm,  and  the  woman  should  be  sure  to  wear  flannel;  and,  to 
conclude,  let  the  strength,  as  to  feeble,  lymphatic  persons,  be  sus- 
tained by  a good  diet  and  a glass  of  good  Bordeaux  claret  at  meal 
times. 

[Notwithstanding  the  favourable  prognosis  in  this  case,  offered  by  Dela- 
inotte,  and  confirmed  by  M.  Colombat,  I do  not  think  that  the  younger 
practitioner  ought  to  found  thereon  a careless  confidence  as  to  the  safety  of 
either  the  patient  or  foetus.  It  is  true  that  a simple  oedema  may  not  offer 
the  least  obstruction  to  the  escape  of  the  foetus  in  labour;  and  it  is  in  fact 
found  that  many  women,  very  considerably  infiltrated,  do  pass  through  the 
several  stages  of  parturition  with  the  greatest  facility;  but  I wish  to  warn 
he  younger  portion  of  our  readers,  that  if  the  patient  be  in  a first  pregnancy, 
and  if  the  tumour  of  the  limbs  and  body  be  of  the  elastic  sort  mentioned  by 
M.  Colombat,  the  medical  attendant  should  take  good  heed  as  to  the  circula- 
tion, the  innervation,  the  state  of  the  patient’s  temper,  her  sleep,  &c.,  for  she 
ought  to  be  esteemed  as  highly  liable  to  attacks  of  eclampsia.  In  a woman 
who  has  already  borne  several  children,  I deem  the  danger  of  eclampsia 
to  be  less  imminent,  under  these  circumstances,  in  consequence  of  the 
greater  laxity  of  fibre  which,  in  such  persons,  admits  of  freer  distension  of 


CEPHALALGIA  AND  VERTIGO. 


627 


the  cellular  tissue,  and  that,  without  too  great  a development  of  nervous  irri- 
tation and  susceptibility.  I offer  these  remarks  additional  to  M.  Colombat’s, 
under  a sense  of  the  deeply  distressing  and  alarming  cases  of  puerperal  con- 
vulsions that  I have  met  with  in  my  own  practice  and  in  consultations; 
cases  which  I deemed  clearly  traceable  to  a close  connection  with  an  exces- 
sive distension  of  the  cellular  tela  and  skin,  arising  from  the  oedema  or  ana- 
sarca of  pregnant  women.  1 know  not  why  the  mere  infiltration  of  the  cellular 
tissue  should  produce  so  great  a tendency  to  attacks  of  puerperal  convulsion, 
but  I feel  very  confident  that  the  primiparous  female,  who  is  affected  with 
the  more  firm  and  elastic  sort  of  oedema,  is  very  prone  to  suffer  in  this  way. 
The  pressure  on  the  veins  and  absorbents  producing  oedema,  coincides  with 
pressure  on  the  aorta  producing  determination  to  the  head. — M.] 


OF  CEPHALALGIA  AND  VERTIGO. 

Affections  of  the  brain  occurring  during  pregnancy. 

Cephalalgia  and  vertigo  are  frequently  found  to  complicate  preg- 
nancy, in  consequence  of  a state  of  nervous  excitement  or  of  a ple- 
thoric condition.  The  first-named  variety  of  cephalalgia  is  principally 
to  be  observed  in  women  of  a delicate  habit  of  body,  and  may  arise 
under  the  influence  of  vivid  impressions  on  the  mind,  such  as  grief, 
disappointment,  rage,  &c.  The  second,  which  is  common  in  women 
of  a sanguine  temperament  and  robust  constitution,  appears  to  depend 
upon  whatsoever  tends  to  augment  the  nutritive  materials  and  the 
abundance  of  the  hsematosis. 

There  is*a  third  species  of  cephalalgia  ; it  is  that  which  depends  on 
the  state  of  the  stomach,  or  on  some  gastric  disorder,  evinced  by  bit- 
terness of  the  mouth,  a whitish  or  yellowish  induitus  of  the  tongue, 
and  a more  or  less  decided  want  of  appetite.  In  these  cases  the  head- 
ache is  lancinating,  and  increased  after  each  meal ; but  there  are 
intervals  of  calm  between  the  attacks. 

Those  pains  that  depend  upon  nervous  irritation,  are  met  with 
chiefly  in  the  earlier  months  of  gestation,  and  grow  less  and  less 
severe  as  pregnancy  approaches  towards  the  full  term.  Further- 
more, where  the  headache  is  connected  with  a state  of  plethora,  it 
does  not  commonly  come  on  before  the  fourth  month,  and  it  then 
begins  with  a pain  above  the  brows,  and  a sort  of  stupor  and  heavi- 
ness of  the  head,  accompanied  with  pain  in  moving  the  eyelids  and 
eyes,  which  seem  to  be  more  sparkling  than  usual,  and  which,  be- 
sides, are  not  at  ease  in  their  orbits. 

The  treatment  of  these  different  kinds  of  pain  ought  to  vary 
according  to  the  causes  that  give  rise  to  them.  To  the  nervous  head- 
aches, for  example,  we  should  oppose  the  sedative,  soothing  articles 
of  the  materia  medica,  antispasmodics,  baths,  enemata;  the  t hr  id  ace  ; 
opium  and  camphor,  administered  internally;  the  inspiration  of 
ether,  of  Cologne  water,  and  eau  des  carmes;  and,  lastly,  rest  and 
sleep.  A plethoric  headache  may  be  advantageously  met  by  vene- 
section, and  especially  by  arteriotomy.  The  effects  of  these  measures 
may  be  seconded  by  a mild  regimen,  more  especially  a vegetable 


628 


SLEEPLESSNESS. 


one,  by  dilating  drinks,  and  the  employment  of  injections  and  laxa- 
tives, for  the  purpose  of  keeping  the  bowels  in  a soluble  state.  In 
fine,  we  should  direct  the  use  of  lemonades,  vegetable  broths,  saline 
cathartics,  Seidlitz  or  Pulna  water,  and,  in  some  cases,  ipecacuanha, 
with  the  design  to  combat  the  cephalalgia  and  vertigo,  seemingly 
dependent  upon  a disordered  stomach. 

[Let  the  physician  be  aware  of  the  danger  of  headache  in  women  in  ad- 
vanced stages  of  gestation.  A severe  headache,  and  especially  one  accom- 
panied with  a sense  of  weight  on  the  crown,  or  a severe  pain  that  can  be 
covered  with  the  thumb,  is  but  one  step  removed  from  eclampsia.  Such  a 
person  ought  to  be  bled  freely  at  the  arm,  if  it  be  possible  to  do  so  without 
flying  in  the  very  face  of  powerful  counter-indications.  I have  not  spared  the 
lancet  in  many  such ; but  I mav  confidently  assert  that  where  I have  done 
so,  I have  had  cause  most  bitterly  to  regret  it. 

A severe  headache  in  a woman  advanced  in  pregnancy,  should  be  taken 
as  the  sign  that  she  ought  to  be  let  blood — almost,  I was  about  to  add,  with- 
out inquiring  of  the  pulse. — M.] 

INSOMNIA,  OR  AGRYPNIA. 

Sleeplessness  is  one  of  the  most  distressing  affections  to  which  the 
pregnant  female  is  liable.  Women  of  a nervous  and  delicate  consti- 
tution are  much  more  liable  to  such  an  affection  than  the  plethoric 
sort,  who,  on  the  contrary,  are  sometimes  disposed  to  sleep  or  be 
drowsy  all  the  time. 

The  insomnia  that  occurs  in  pregnancy  is  most  generally  a neurosis, 
which  depends  upon  cerebral  exaltation  arising  from  sympathy  with 
the  uterine  system.  In  some  instances,  however,  both  the  sleepless- 
ness and  the  drowsiness  of  pregnant  women  are  owing  to  a plethoric 
condition,  evinced  by  the  high  colour  of  the  face  and  eyes,  the  gene- 
ral agitation  of  the  system,  and  the  strength  and  hardness  of  the 
pulse. 

In  slight  cases  of  insomnia,  the  treatment  consists  in  moderate 
exercise  of  the  body,  a soothing  regimen,  anodyne  enemata,  syrup  of 
thridace,  but  where  the  agitation  is  greatly  prolonged,  it  should  be  met 
by  opiate-emulsions,  syrup  of  diacodiiun,  syrup  of  white  poppies,  and 
particularly  by  acetate  of  morphia,  in  doses  of  a centigramme  for 
each  potion.  Should  the  patient  be  constipated,  the  bowels  should 
be  freed,  by  enemata  or  laxatives,  and  tonics  combined  with  seda- 
tives and  antispasmodics  are  adapted  for  women  who  are  debilitated, 
and  who  have  a naturally  feeble  constitution. 

For  those  cases  of  insomnia  that  are  coincident  with  a plethoric 
habit  of  body  we  should  direct  a venesection,  which. is,  under  such 
circumstances,,  the  first  and  the  best  of  sedatives. 

QNot  merely  to  cure  the  vigil,  but,  what  is  far  more  important,  to  ward 
off  the  attack  of  convulsion  or  apoplexy,  which  should  be  held  as  a threatened, 
and  even  as  an  imminent  danger  for  persons  in  whom  the  insomnia  has 
arisen  to  a considerable  height. — M.] 


AFFECTIONS  OF  THE  SENSES. 


629 


The  beneficial  influence  of  a blood-letting  may  be  powerfully 
seconded  by  the  use  of  the  bath,  of  diluent  drinks,  and  by  almond 
emulsions,  and  lemonade. 

LESIONS  OF  THE  SIGHT,  THE  HEARING,  THE  SMELL,  &c. 

The  various  ophthalmic  neuroses,  as  amaurosis,  diplopia,  nycta- 
lopia, hemeralopia,  and  sparkling  lights  in  the  eyes,  are  often  observed 
to  affect  pregnant  women.  These  disorders,  that  are  particularly 
prevalent  in  nervous  women,  may  be  continued,  or  may  cease  for 
awhile,  and  then  reappear,  and  afterwards  cease  altogether,  which 
for  the  most  part  happens  after  the  accouchement.  Thus,  there  are 
women  who,  after  being  for  several  months  affected  with  amaurosis, 
recover  their  sight  as  soon  as  they  are  confined.  The  same  may 
be  said  as  to  all  the  disorders  of  vision,  such  as  those  in  which 
objects  are  seen  double,  or  under  changes  of  shape  or  colour,  or  ' 
where  they  are  magnified  or  lessened  in  size. 

Sometimes  these  ocular  neuroses  come  on  towards  the  close  of  ges- 
tation, and  especially  is  it  the  case  in  plethoric  persons ; they  are  then 
caused  by  a sanguine  congestion  of  the  head.  In  others,  they  depend 
upon  a nervous  cause,  and  an  extreme  degree  of  sensibility  of  the 
nerves  of  the  eye,  particularly  of  the  retina.  Neuroses  of  this  sort, 
come  on  without  pain,  redness  or  fulness  of  the  eyes.  The  former 
kind,  such  as  are  complicated  with  sanguine  congestion,  are  attended 
with  uneasiness,  pain,  redness,  swelling  of  the  eyes,  turgescence  of 
the  features,  stupor  or  drowsiness.  Furthermore,  in  both  these  kinds 
of  ophthalmic  neuroses,  there  is  blindness  more  or  less  complete, 
or  perhaps  simple  flashings  of  light  in  the  eyes,  and  optical  illu- 
sions, which  create  imaginary  objects,  or  change  the  shape,  size,  and 
volume  of  real  ones  In  some  instances,  likewise,  the  engorgement 
of  the  eyes  may  merely  produce  an  ecchymosis,  or  a real  inflamma- 
tion of  the  conjunctiva,  as  in  the  instances  reported  by  Bartholin  and 
several  other  authorities. 

The  treatment  of  these  affections  differs  according  to  their  several 
causes  and  the  constitution  of  the  individual.  Ophthalmic  neuroses 
of  a nervous  origin  require  to  be  corrected  by  antispasmodics,  opiates 
and  tonics,  such  as  pills  of  cynogloss,  syrup  of  valerian,  and  cinchona, 
or  these  two  last-named  articles  in  powder.  Where  the  woman  is  ple- 
thoric, and  the  neurosis  seems  connected  with  a cerebral  engorgement, 
recourse  is  to  be  had  to  blood-letting,  dieting,  a diluting  regimen, 
enemata,  derivatives  to  the  inferior  extremities,  and  gentle  purga- 
tives, especially  calomel,  in  doses  of  three  or  four  grains  daily. 

Like  the  neuroses  above  treated  of,  the  neuroses  of  the  sense  of 
hearing  attack  nervous  females,  and  those  who  are  of  a plethoric  con- 
stitution. The  patients  first  hear  a buzzing  noise  in  the  ears,  and  sup- 
pose they  are  hearing  real  sounds  of  different  kinds,  or  they  suppose 
they  have  increased  or  diminished  auditory  power,  or  there  is  some 
discordance  betwixt  the  perceptions  and  the  sounds. 

The  treatment,  like  that  of  the  neuroses  of  vision,  consists  in  the 
use  of  antispasmodics  and  opiates,  provided  the  affection  is  due  to  a 


630 


AFFECTIONS  OF  THE  SENSES. 


nervous  condition,  and  in  venesection  and  derivatives  when  it  is  con- 
nected with  a state  of  plethora. 

As  to  the  neuroses  and  anomalies  of  the  senses  of  smell  and  taste, 
to  which  pregnant  women  are  obnoxious,  they  generally  require  no 
regular  treatment ; for  they  almost  always  disappear  spontaneously 
soon  after  the  confinement,  for  they  are  results  of  a sympathetic  in- 
fluence of  the  womb. 

[I  cannot  agree  with  M.  Colombat  in  all  this  opinion,  since  the  affections  of 
the  hearing,  notwithstanding  they  may  in  some  instances  arise  from  a mere 
sympathy  with  the  womb,  yet  cannot  be  known  to  do  so  except  by  the 
event.  The  sudden  abolition  or  extraordinary  mutation  of  power  as  to  one 
of  the  senses,  like  similar  changes  as  to  the  activity  or  obedience  of  a muscle, 
should  be  regarded  as  evidence  of  pressure  or  of  irritation  at  the  source  of 
the  nerve  power  in  question,  and  in  the  event  of  either  of  the  theories  being 
adopted,  the  case  becomes  one  of  startling  interest.  I had  a young  lady 
under  my  care  during  her  pregnancy,  in  which  she  suffered  with  attacks  of 
headache,  for  which  she  received  the  appropriate  treatment.  On  one  occa- 
sion, when  about  eight  months  and  a half  gone  with  child,  she  went  to  a 
drawer  of  her  bureau  to  look  at  some  papers,  and  while  standing  before  it 
thought  she  heard  a loud  explosion,  and  received  a violent  blow  on  the  head. 
She  informed  me  that  the  sound  was  like  that  of  a heavily-charged  musket, 
and  the  blow  felt  as  if  some  one  had  struck  her  head  with  an  axe.  She 
was  stunned  for  a moment,  and  when  the  painful  sensation  had  disappeared 
she  could  only  see  half  of  the  paper,  and  half  of  any  thing  that  she  looked 
at.  I was  called  to  her,  and  upon  arriving,  learned  that  she  could  see  only 
the  right  half  of  my  face,  half  a bed-post,  window-blind,  or  whatsoever  ob- 
ject she  looked  at.  I need  not  say  that  I felt  very  great  concern  for  the 
internal  affection  that  had  given  rise  to  these  symptoms,  and  that  I imme- 
diately bled  her  copiously,  after  which  she  recovered. 

fl'he  late  distinguished  surgeon,  Dr.  Physick,  was  called  to  a gentleman 
here  who  suddenly  lost  his  hearing — it  was  absolutely  gone — the  sense 
being  for  the  time  completely  abolished.  Dr.  P.  looked  upon  him  as  suffer- 
ing from  pressure  at  the  sources  of  the  auditory  nerves,  and  treated  him  by 
the  most  liberal  venesection,  after  which  his  hearing  immediately  returned. 
He  died  some  years  afterwards,  of  a series  of  paralytic  attacks,  terminating 
at  length  in  apoplexy. 

If  a woman  in  labour  should  say,  Sir,  I cannot  see  you — the  room  has 
been  darkened,  or  should  she  say,  I see  every  object  doubled,  or  only  half 
of  any  object,  I esteem  it  far  more  prudent  to  look  upon  the  complaint  as 
one  exigent  of  immediate  treatment,  than  to  say,  along  with  M.  Colom- 
bat, that  it  arises  from  sympathy  with  the  womb,  and  pass  it  lightly  by. 

A woman  in  labour  said  to  me,  “ Doctor,  what  is  the  matter,  sir,  I cannot 
see  you.”  “ Give  me  a bandage  and  basin,”  said  I to  the  nurse,  “quick, 
quick,” — but  before  I could  tie  up  the  arm  she  was  in  eclampsia. — M.] 


631 


DISORDERED  INTELLECT,  ETC. 

DISORDERS  OF  THE  INTELLIGENCE  AND  OF  THE  MORAL  INCLINA- 
TIONS AND  AFFECTIONS. 

Although  the  modifications  that  gestation  introduces  into  the  intel- 
lectual faculties  and  the  moral  inclinations  and  affections,  have  been 
greatly  exaggerated,  it  is  nevertheless  true  that,  insanity,  certain  forms 
of  monomania,  and  certain  disorders  of  the  understanding  often  come 
on  during  gestation.  It  is  very  certain  that  pregnancy  exalts  the 
sensibility  and  the  susceptibility,  and  disposes  the  person  to  nervous 
disorders. 

We  shall  pass  over,  in  silence,  the  antipathies  and  the  sympathies, 
the  queer  temper,  the  headstrong  character,  the  melancholy,  perverse 
or  irascible  humour  that  displays  itself  of  a sudden,  in  females  of  the 
mildest  and  most  even  temper.  Women  have  been  known  to  be- 
come thievish,  poetical  or  musical,  from  being  pregnant,  while  others 
in  that  situation  lose  all  intellectual  activity,  and  some  have  all  their 
intellectual  powers  either  elevated  or  depressed  in  force.  Goubellv 
speaks  of  a woman  who  never  had  a sound  judgment  except  when 
she  was  pregnant ; but  she  then  lost  her  memory,  which,  after  her 
delivery,  she  recovered,  but  at  the  expense  of  no  judgment.  Baude- 
locque  mentions  a pregnant  woman  who  ate  nothing  with  so  much 
pleasure  as  the  articles  of  food  that  she  had  stolen,  while  going  to 
market  for  her  provisions.  Roderick  a Castro  tells  us  of  another 
female  who  wanted  to  eat  a piece  of  the  baker’s  shoulder,  and  Lan- 
grus,  of  another  who,  longing  to  eat  a piece  of  the  flesh  of  her 
husband,  whom  she  tenderly  loved,  assassinated  him  to  satisfy  her 
ferocious  appetite,  and  then  salted  down  some  parts  of  the  body, 
with  a view  to  prolong  the  pleasure.  Vives  speaks  of  a woman  who 
would,  perhaps,  have  miscarried,  had  she  not  been  allowed  to  bite  a 
young  man’s  neck,  one  of  her  acquaintances.  In  1816,  a woman  at 
Mons  threw  three  of  her  children  into  a well,  and  then  plunged  to 
the  bottom  herself.  She  had  two  other  children,  one  at  boarding- 
school  and  the  other  with  a wet  nurse : happily  for  them,  the  young- 
est had  not  been  sent  to  her  in  time,  agreeably  to  her  order,  and  the 
elder  child  did  not  take  any  of  the  poisoned  cake  that  she  sent  it. 

Generally  speaking,  all  these  caprices,  all  these  oddities  and  ma- 
niacal states,  disappear  after  delivery:  insanity,  however,  which, 
besides,  does  not  come  on  until  after  the  parturition,  (puerperal  in- 
sanity,) sometimes  continues  throughout  the  lifetime  of  the  patient. 
The  therapeutical  treatment,  under  such  circumstances,  is  almost 
always  impotent,  and  consists,  indeed,  almost  wholly  in  a few 
bleedings,  some  counter-irritants  to  the  skin,  and  derivatives  applied 
through  the  intestinal  tube. 

[M.  Colombat  says  truly,  that  puerperal  mania  does,  in  some  instances, 
last  as  long  as  the  life  of  the  patient;  but  it  would  be  wrong  to  assume  from 
this,  that  the  cases  of  non-recovery  are  few.  On  the  contrary,  the  cases  of 
recovery  are  numerous,  while  those  of  persistent  mental  alienation  are  very 
few,  and  those  in  which  death  occurs  are  very  rare,  indeed.  Dr.  William 
Hunter,  of  London,  was  asked  what  opinion  he  had  formed  as  to  the  pros- 


632 


PUERPERAL  CONVULSIONS. 


pect  of  recovery  of  a lady  who  had  been  brought  to  London  to  see  him. 
“Ah,  that’s  not  the  question  in  these  cases,”  replied  he;  “the  question  is 
not  whether  the  patient  is  to  recover,  but  when?”  If  Dr.  Hunter  ever  made 
the  above  remark,  it  should  be  deemed  a consolatory  item  in  the  budget  of 
distress  connected  with  such  cases,  since  his  great  judgment  and  experience 
have  been  almost  universally  acknowledged ; yet  it  is  true  to  say,  that  not 
a very  few  persons,  seized  with  the  symptoms  of  puerperal  mania,  perish, 
sooner  or  later,  from  lesions  of  the  encephalon,  consisting  of  softening,  or 
effusion  or  even  extravasation  of  blood  within  the  parietes  of  the  cranium. 
M.] 


OF  ECLAMPSIA,  OR  PUERPERAL  CONVULSIONS. 

By  the  term  eclampsia,  eclampsia  parturientium,  from  the  Greek 
fX^pL^is,Jiash  of  light,  is  understood  the  epileptiform  attack  of  con- 
vulsions depending  upon  the  puerperal  state,  that  is  to  say,  those 
that  are  met  with  in  pregnant  women,  in  women  in  labour,  or  those 
who  have  been  recently  delivered.  Although  the  convulsions  may 
exhibit  themselves  in  the  puerperal  state,  under  the  form  of  hysteria, 
tetanus  and  catalepsy,  we  esteem  it  best  to  say  but  a few  words  on 
them,  in  order  to  afford  space  for  fuller  detail  on  the  subject  of  the  epi- 
leptiform cases,  since  the  former  sort  are  always  less  serious,  exhibit 
much  less  alarming  symptoms,  and  require  pretty  much  the  same 
treatment  as  the  epileptic  kinds.  Furthermore,  cases  of  cataleptic  and 
tetanic  puerperal  convulsions  are  so  rare  that  even  M.  Dubois  him- 
self has  never  had  an  opportunity  to  meet  with  a case. 

The  frequency  of  eclampsia,  or  epileptiform  puerperal  convulsions, 
cannot  be  accurately  established ; for  the  statistical  results  obtained 
in  various  countries,  and  at  different  periods,  show  the  most  enor- 
mous discrepancies  amongst  themselves.  In  fact,  from  the  statistical 
statements,  extending  from  1829  to  1S42,  at  the  Paris  Mat  emit  6 and 
at  the  Clinique  d’ Accouchement s,  the  disease  occurred  only  ten 
times  in  12,500  women,  or  once  in  1250  cases ; while,  at  Dublin,  the 
statistical  report  shows  thirty  cases  in  1600,  that  is  to  say,  one  in 
every  53  women;  an  enormous  difference,  which  no  circumstances 
can  explain  or  account  for. 

The  causes  of  eclampsia  ought  to  be  divided  into  predisponent 
and  occasional  causes.  Amongst  the  number  of  the  former,  there  is 
one  that  ought  to  be  deemed  essential,  and  as  occupying  the  first 
rank,  to  wit,  the.  puerperal  state,  which  lends  energy  and  power  to 
all  the  other  causes,  which,  in  the  common  course  of  life,  may  give  a 
predisposition  to  convulsive  disorders.  It  should  be  stated,  however, 
that  the  puerperal  state  does  not  constitute  a predisposition  to 
eclampsia,  except  when  accompanied  by  other  conditions  that  de- 
velop the  predisposition  in  a still  higher  degree.  The  first  in  order, 
of  these  conditions,  is  undoubtedly  the  primiparous  state ; for, 
according  to  a statement  made  by  Dr.  Collins,  of  Dublin,  there  were 
seventy-five  primiparous  women  in  eighty-five  cases  of  convulsive 
attack  during  pregnancy  and  lying-in.  Nevertheless,  women  who 


PUERPERAL  CONVULSIONS. 


633 


have  had  children  are*  also  liable  to  convulsion ; but  they  are  so 
under  the  influence  of  other  causes,  that  we  shall  make  known,  and 
which  exert  a direct  influence  on  the  production  of  the  accidents. 
Women  in  their  first  pregnancy  are  more  liable  to  eclampsia,  only 
because  in  them  the  uterus  enjoys  a higher  degree  of  susceptibility, 
and  the  labour,  moreover,  is  longer  and  more  painful.  Among  the 
predisponent  causes  of  the  disorder,  we  ought  also  to  class  the  dis- 
tension of  the  womb  by  twins,  or  by  an  unusual  quantity  of  water, 
which  almost  always  coincides  with  a serous  diathesis  and  considera- 
ble infiltration  of  the  inferior  extremities.  The  sanguine  tempera- 
ment, and  particularly  the  lymphatic  temperament,  with  general  or 
partial  oedema  of  the  cellular  tela,  are  rationally,  by  many  authors, 
regarded  as  conditions  essential  to  the  production  of  eclampsia. 
The  isolated  influence  of  the  nervous  temperament  is  less  marked 
than  that  of  the  other  states  above  mentioned ; but  a decided  rachitic 
condition  seems  to  have  a very  decided  influence  in  the  production 
of  the  disease  for  eclampsic  convulsions,  and  are  more  frequently 
noticed  in  rachitic  females,  than  in  such  as  are  well  formed. 

[M.  Colombat  appears  to  me  to  beg  the  question  here;  and  he  atlributes 
to  the  disease  what  should  more  fairly  be  assigned  to  the  influence  of  the 
products  or  consequences  of  the  disease.  A woman  may  enjoy  the  most 
robust  and  vigorous  health,  notwithstanding  she  may,  in  early  life,  have 
suffered  great  distortion  of  the  spine,  the  pelvis,  and  of  other  parts  of  her 
osseous  structure.  She  was  rachitic,  as  a child ; but,  as  a woman,  she 
is  in  sound  health.  Such  a woman  is  exposed  to  the  extremity  of  nervous 
perturbation  by  the  opposition  of  her  rickety  pelvis  to  the  delivery  of  her 
foetus,  in  labour;  and,  in  so  far,  may  be  regarded  as  liable  to  convulsions. 
It  may  be  true  that  she  is  so ; but  I have  not  met  with  convulsions  in 
any  one  of  the  cases  of  labour,  with  distorted  pelvis,  that  has  been  under 
my  care.  M.  C.  goes  on  to  say  that: — M.] 

A deformity  of  the  pelvis,  a bad  position  of  the  child,  a dispropor- 
tion between  its  parts,  and  the  passages  it  is  to  traverse,  and,  indeed, 
an  excess  of  sensibility  of  the  womb,  are  likewise  so  many  circum- 
stances that  predispose  the  patient  to  the  puerperal  convulsion. 

Particular  states  of  the  atmosphere  have  also  been  classed  among 
the  predisponent  causes  of  eclampsia.  Smellie,  Desormeaux,  Mad. 
Lachapelle,  M.  Bouteillier,  and  some  others  have  remarked  that 
the  disorder  sometimes  prevails  epidemically.  It  may,  likewise,  be 
brought  on  by  the  power  of  imitation,  or  by  fright  from  seeing  a 
woman  seized  with  convulsions,  which  has  often  been  clearly  ob- 
served in  the  lying-in  wards  of  a hospital.  One  may  also  perceive 
that  whatsoever  tends  to  excite  the  general  irritability  of  the  con- 
stitution, may  constitute  a predisposition ; it  is  in  this  way  that  we 
discover  the  effects  of  imprudence  in  eating,  and  disorders  in  the 
exercise  of  other  functions  of  the  economy ; the  use  of  high-sea- 

* Women  have  been  seized  with  eclampsic  convulsions  in  the  second,  third,  fourth, 
fifth,  and  even  in  the  eleventh  pregnancy. 


634 


PUERPERAL  CONVULSIONS. 


soned  food,  a depraved  appetite  frequently  gratified,  attacks  of  indi- 
gestion, the  abuse  of  coffee,  drunkenness,  abuses  of  coitus,  especially 
in  the  latter  months  of  pregnancy,  the  abuse  of  alcoholic  drinks,  the 
impressions  made  by  odours,  the  use  of  tight  dresses  or  corsets,  and, 
in  fine,  the  effect  of  the  passions,  whether  of  joy  or  grief — and  all  the 
more  powerful  emotions  of  the  soul. 

It  would  appear,  from  a considerable  number  of  observed  cases, 
that  eclampsia  is  less  common  with  poor  country  women  than  with 
the  easier  classes  of  cities,  who  are,  generally,  more  excitable  and  of 
a more  nervous  and  active  temperament.  It  is  right,  however,  to 
remark,  that  puerperal  convulsions  are  principally  to  be  met  with  in 
the  hospitals  of  large  cities,  and^  of  course,  among  the  more  wretched 
classes,  who,  in  fact,  partake  of  the  same  nervous  predominance  as 
appertains  to  the  wealthier  females,  and  is,  moreover,  connected  with 
most  unfavourable  hygienic  conditions. 

The  operation  of  the  predisponent  causes  does  not,  necessarily, 
result  in  the  production  of  the  epileptiform  convulsion,  and,  as  it 
serves  merely  to  place  the  economy  in  an  attitude  favourable  to  the 
development  of  the  attack,  some  occasional  circumstance  must  of 
necessity  intervene,  in  order  that  the  disease  may  make  itself  mani- 
fest. 

Among  these  occasional  circumstances  we  ought  to  place  in  the 
first  rank  the  pains  of  labour.  In  fact,  the  attack  of  eclampsia  does 
most  commonly  take  place  just  as  the  head  is  escaping  from  the 
circle  of  the  os  uteri,  or  from  the  vulva,  or,  in  other  words,  at  the 
period  when  the  labour  pain  has  reached  the  summum  of  its  inten- 
sity. It  happens,  especially  where  the  pains  are  protracted  an  inor- 
dinate length,  in  consequence  of  some  obstacle,  such  as  rigidity, 
hardness,  or  spasms  of  the  cervix,  unusual  tenacity  of  the  mem- 
branes, a cancer  of  the  womb,  an  occlusion  or  extraordinary  con- 
traction of  the  os  tineas,  a calculus  in  the  bladder,  or  an  extremely 
distended  state  of  the  bladder,  a polypus  or  any  tumour  within  the 
pelvic  cavity,  a rupture  of  the  womb,  or  the  laceration  of  its  cervix ; 
in  fine,  a disproportionate  size,  or  the  death  of  the  foetus;  a bad 
position  of  the  child ; twin  pregnancy,  and  the  various  manoeuvres 
required  in  the  operation  for  turning  the  child  or  delivery  by  the 
forceps.  It  should  be  added  farther,  that  strong  moral  impressions, 
such  as  anger,  vexation,  fright  and  joy  may  at  this  period  become 
determining  causes  of  eclampsia. 

Dr.  Burns,  an  English  physician,  thinks  that  the  compression  of 
the  sacral  nerves,  either  by  the  child’s  head  or  by  the  forceps,  should 
be  regarded  as  an  immediate  cause  of  the  disorder  under  consider- 
ation : a circumstance  that  might  be  considered  as  proof  of  the 
soundness  of  this  opinion  as  to  some  of  the  instances,  is  this,  namely, 
that  in  eclampsia  the  head  is  very  frequently  in  an  occipito-posterior 
position.  However,  it  is  our  opinion,  that  the  determining  cause  of 
eclampsia  occurring  during  the  course  of  pregnancy  is  a result  of 
exaggerated  sympathetic  reaction  of  the  womb  upon  the  nervous 
system.  It  is  to  be  remarked,  that  convulsions  occurring  during  the 
progress  of  gestation  may  cause  abortion  to  take  place,  or  they 


PUERPERAL  CONVULSIONS. 


635 


may  occasion  the  death  of  the  foetus  and  a premature  confinement. 
Labour  under  such  circumstances  goes  on  more  rapidly  than  in  ordi- 
nary cases,  and  almost  always  without  the  consciousness  of  the 
patient,  who  appears  to  feel  no  pain,  or  at  least  gives  no  sign  of  suf- 
fering beyond  a low  grunting  sound. 

Puerperal  convulsion  may  be  also  caused  after  delivery,  by  the 
presence  of  coagula  in  the  womb,  or  by  remnants  of  the  placenta, 
or  of  false  membranes,  retained  within  the  cavity.  In  such  cases 
the  convulsive  paroxysms  succeed  the  expulsive  efforts;  they  may 
also  be  brought  on  by  lesions  and  lacerations  of  the  womb,  by 
exposure  to  cold,  and  by  walking  about  too  soon  after  delivery,  and 
sometimes  by  metritis  and  peritonitis,  which  produce  suppression  of 
the  lochia,  itself  a mere  symptom  that  has  been  erroneously  regarded 
as  a cause  of  eclampsia.  The  same  may  be  said  as  to  flooding 
after  delivery,  which  brings  on  convulsions,  that  are,  however,  of  a 
nature  different  from  those  in  question.  The  precursory  signs  of  the 
disorder  are  numerous  and  varied,  but  sometimes  so  slight  that  they 
excite  little  attention.  They  consist  in  a fixed  pain  in  the  head, 
with  disordered  intellect, sensibility  and  mobility;  an  extreme  degree 
of  uneasiness;  flashing  of  light  in  the  eyes,  vertigo,  hallucinations; 
diminished  power  of  sight  and  hearing ; confusion  of  ideas  and  of 
the  speech.  The  eyes  are  by  turns  fixed  and  rolling,  their  pupils 
are  dilated ; there  is  shuddering  of  the  limbs,  accompanied  by  slight 
convulsive  twitchings  of  the  muscles  of  the  face,  which  appears  some- 
what swelled  and  flushed;  these  prodromes  are  often  followed  by 
vomiting,  involuntary  discharge  of  the  faeces,  and  likewise  by  violent 
pains  at  the  epigastrium ; sometimes,  however,  the  attack  comes  on 
without  any  apparent  precursory  sign. 

The  attack  is  announced  by  symptoms  peculiar  to  it;  the  wo- 
man is  excessive^  agitated  and  uncontrollable,  the  countenance 
assumes  a bluish  or  violaceous  tint,  the  look  becomes  fixed,  the 
globe  of  the  eye  turns  up  under  the  upper  lid,  the  nostrils  are 
distended,  the  angles  of  the  mouth  are  drawn  backwards,  the  chin 
seems  sharpened,  and  the  features  resemble  those  of  a satyr.  At 
the  same  time  the  trunk  becomes  rigid,  and  the  hands  are  con- 
vulsively clenched,  the  head  turns  over  backwards,  and  through 
the  half-open  mouth  the  tongue  is  projected  forth.  The  forearms 
acquire  a very  rigid  tension  and  are  excessively  pronated,  the  legs 
are  extended  upon  the  thighs,  the  feet  and  toes  are  strongly  flexed ; 
the  body,  which  is  bent  backwards,  often  seems  to  rest  only  on  the 
heels  and  the  occiput,  like  two  ends  of  a bow ; and  the  jaws  are  so 
forcibly  clenched  that  the  tongue,  in  many  of  the  examples,  is  deeply 
wounded.  One  remark  on  this  subject  is,  that,  in  general,  one  side 
of  the  body  is  more  convulsed  than  the  other ; but  the  motions  are 
limited  in  all  the  cases,  consisting  of  little  more  than  a sort  of  trem- 
bling, which  serves  to  distinguish  the  puerperal  from  the  hysterical 
kind  of  convulsions ; the  latter  sort  being  characterized  by  extensive 
and  violent  motions. 

During  the  attack  the  respiration,  which  is  at  first  rapid  and 
jerking,  becomes  suspended,  while  the  muscles  refuse  to  dilate  the 


636 


PUERPERAL  CONVULSIONS. 


thorax,  or  while  the  glottis  is  closed  by  spasm ; when  the  air,  how- 
ever, escapes  from  the  lungs,  the  breathing,  which  is  suspirious  and 
loud,  produces  a hissing  sound,  owing  to  the  rush  of  the  air  betwixt 
the  clenched  teeth,  carrying  with  it  abundance  of  the  saliva,  which 
inundates  the  whole  mouth.  The  circulation  is  also  very  irregular, 
and  the  arterial  pulse  becomes  so  feeble  and  disordered  that,  at 
times,  there  is  a real  suspension  of  the  motions  of  the  heart. 
Further,  throughout  the  whole  duration  of  the  attack,  the  sensibility 
of  the  patient  is  completely  nullified,  the  intellection  wholly  disap- 
pears, and  sight  and  sound  are  no  longer  perceived,  while  the  skin 
fails  to  perceive  even  the  most  violent  excitants  that  can  be  applied 
to  it.  All  these  symptoms  last  during  some  few  minutes,  and  the  re- 
spiration and  circulation  then  gradually  resume  their  natural  rhythm; 
the  close  of  the  attack  is  announced  by  a return  of  warmth  to  the  sur- 
face, and  by  a general  perspiration,  and,  above  all,  by  diminution  of 
the  convulsions,  which,  though  they  are  more  violent,  yet  recur  after 
longer  and  still  longer  intervals. 

The  convulsions  are  followed  by  a state  of  stupor,  complete  relax- 
ation of  the  limbs,  loss  of  sense,  feeling  and  memory,  and  apoplectic 
somnolency,  accompanied  with  stertorous  breathing,  interrupted  by 
moanings,  and  a complete  forgetfulness  of  all  that  has  transpired 
during  the  attack. 

The  duration  of  the  attack  varies  from  three  to  five  and  even  to 
ten  minutes ; but  we  doubt  whether  it  can  exist  during  ten  hours 
out  of  the  twenty -four,  as  in  a case  mentioned  by  Levret.  It  almost 
always  happens  that  the  attacks  are  repeated,  but  after  each  attack 
the  torpor  and  the  sleep  are  more  prolonged  and  decided,  and  they 
become  more  so  in  proportion  as  they  are  more  frequently  repeated ; 
in  some  cases  they  may  be  found  to  recur  at  determinate  periods. 
Baudelocque  speaks  of  a lady  whose  attacks  occurred  twice  a day 
for  twelve  consecutive  days ; he  adds,  that  the  attacks  always  lasted 
three  hours  and  a half,  which  leads  us  to  suspect  that  the  distin- 
guished accoucheur  may  possibly  have  been  mistaken  as  to  the 
nature  of  the  convulsion,  as  attacks  of  eclampsia  could  not  be  very 
greatly  prolonged  without  destroying  the  patient.  In  fine,  the  con- 
vulsions may  come  on  at  intervals  of  five  minutes  consecutively,  or 
every  fifteen  minutes,  and  they  may  be  separated  by  intervals  of  a 
whole  day,  or  of  several  days. 

Generally  speaking,  the  disorder  terminates  fatally  in  half  the 
cases;  or  it  may  be  followed  by  restoration  to  perfect  health— or  it 
may  result  in  the  development  of  some  other  disease,  of  greater  or 
less  severity. 

[M.  Oolombat  says  that  one-half  of  the  cases  of  puerperal  convulsions 
prove  fatal.  I am  very  sure  that  such  is  not  the  case  in  this  country.  I 
have  met  with  upwards  of  twenty  cases  of  the  affection,  of  which  not  more 
than  three  have  proved  to  be  mortal  cases ; so  that,  instead  of  50  per  cent, 
of  fatalities,  I am  confident  that  the  fatalities  will  not  reach  beyond  14  or 
15  per  cent,  under  a judicious  management  of  the  attack.  By  a note, 
dated  August  31,  1844,  from  my  colleague,  Prof.  Huston,  of  the  Jefferson 


PUERPERAL  CONVULSIONS. 


637 


Medical  College,  I learn  that  his  results  are  very  similar  to  mine,  he  having 
lost  two  only  out  of  thirteen  cases  of  puerperal  eclampsia,  the  amount 
of  his  personal  experience  in  hospital,  in  private  practice  and  in  consult- 
ations, which  is  a mortality  of  not  quite  15  percent.,  instead  of  50  per 
cent.,  as  stated  by  M.  Colombat. 

Dr.  Collins,  of  Dublin,  says,  that  thirty  cases  of  puerperal  convulsions 
occurred  in  the  lying-in  hospital  during  his  mastership,  and  that  five  of  the 
women  died,  giving  a mortality  of  between  16  and  17  per  cent. — M.] 

Death  sometimes  takes  place  during  the  convulsion,  or  in  the  stupor 
that  follows  it ; women  have  been  seen  to  perish  in  the  first  or  the 
second  paroxysm.  History  informs  us  that  the  Duchess  of  Beaufort 
died  in  the  second  paroxysm  of  puerperal  convulsions,  with  which 
she  was  seized  while  writing  to  Henry  IV. 

The  return  to  health  may  be  more  or  less  rapid,  but  it  is  generally 
gradual  ; however,  an  attack  may  take  place  without  leaving  any 
symptoms  whatever  after  it  is  over. 

Lastly,  the  diseases  which  may  be  complicated  with,  or  which  may 
become  sequelse  of  eclampsic  attacks,  are  rupture  of  the  womb,  a 
speedily  fatal  accident,  metro-peritonitis,  paralysis,  or  simple  numb- 
ness of  the  limbs,  disordered  understanding,  and  diseased  sensations, 
mania,  dementia,  amaurosis,  deafness,  cephalalgia,  and  a loss  of 
memory  more  or  less  absolute.  It  should  be  understood  that  these 
several  disorders  may  be  only  transitory,  or  that  they  may  be  indefi- 
nitely prolonged. 

The  prognosis  of  the  case  is  very  serious,  both  as  to  the  mother 
and  her  offspring.  It  is  more  serious  in  primiparous  women  than  in 
such  as  have  had  children  before,  and  it  is  particularly  unfavourable 
for  first  labours  in  women  somewhat  advanced  in  life,  for  women 
not  subject  to  convulsions,  as  hysteria,  epilepsy,  catalepsy,  &c.  The 
prognostic  is  more  serious  in  women  whose  limbs  are  infiltrated,  and 
it  has  been  found  more  fatal  in  hospitals  than  in  private  practice ; 
and  that  the  same  is  true  as  to  cases  occurring  before  the  full  term  of 
pregnancy,  because  the  disorder  is  complicated  with  all  the  hazards 
that  attend  abortion. 

An  attack  coming  on  at  term,  but  before  the  commencement  of 
labour,  is  also  more  dangerous  than  one  that  comes  on  during  the 
progress  of  a labour,  or  towards  its  conclusion,  and  this  latter  is  more 
hazardous  than  one  that  succeeds  to  the  birth  of  the  child  or  the  deli- 
very of  the  secundines.  Lastly,  the  prognosis  will  be  more  or  less 
grave  in  proportion  as  an  attack  is  made  at  a period  less  or  more 
advanced  of  gestation,  inasmuch  as  in  such  a case  the  attacks  might 
continue  until  the  pregnancy  should  be  brought  to  its  close.  How- 
ever, the  disease  is  so  much  the  more  to  be  dreaded  as  the  attacks 
are  nearer  to  each  other,  more  numerous,  more  intense,  longer  in 
duration,  and  as  the  stupor  is  profound  and  enduring.  We  add,  that 
it  is  a good  sign  when  lucid  moments  appear  after  the  coma  in  the 
intervals  of  the  convulsions. 

The  death  of  the  child  is  also  a very  frequent  consequence  of 


638 


PUERPERAL  CONVULSIONS. 


eclampsia,  and  its  danger  is  enhanced  as  the  attacks  are  more  vio- 
lent and  reiterated.  Its  life,  however,  is  less  endangered  when  the 
convulsion  comes  on  before  the  commencement  of  the  labour.  Besides, 
children  born  of  eclarnpsic  mothers  are  more  liable  than  others  to 
die  of  convulsions,  for  they  come  into  the  world  with  symptoms  of 
cerebral  congestion,  and  are  in  a condition  closely  allied  to  that  of 
infants  born  with  compression  of  the  umbilical  cord. 

Examinations  post  mortem  rarely  give  any  satisfactory  explana- 
tion of  the  severity  of  the  symptoms ; in  a great  majority  of  cases,  no 
lesion  is  discovered  to  explain  the  profound  disorder  of  the  nervous 
system.  In  women  who  have  perished  during  the  attack,  there  are 
sometimes  discovered  the  traces  of  a cerebral  congestion,  engorgement 
of  the  encephalic  veins  and  sinuses,  and  sanguine,  but  more  generally 
serous  effusions  where  life  is  closed  in  the  stupor  of  the  disease.  The 
viscera  of  the  other  splanchnic  cavities  exhibit  no  alterations  attribu- 
table to  the  malady.  In  these  cases,  then,  as  in  all  the  neuroses,  the 
material  change  escapes  our  cognition. 

The  diagnosis  of  eclampsia  is  easily  established,  for,  according  to 
the  symptoms  which  we  have  recognized  as  belonging  to  the  epilep- 
tiform sort,  &c.,it  would  always  be  possible  to  distinguish  them  from 
other  affections  exhibiting  analogous  symptoms.  Thus  the  eclamp- 
sic  convulsion  is  characterized  by  movements  of  small  extent,  con- 
centrated, occurring  in  slight  jerks,  and  always  ending  in  stupor  and 
coma.  With  these  characteristics,  it  cannot  be  confounded  with  hys- 
teria. It  is  true  that  there  is  sometimes  confusion  of  these  two  orders 
of  symptoms,  but  the  gravity  and  the  indications  are  always  the  same, 
for  in  this  case  the  hysterical  symptoms  are  transformed  into  those 
that  are  characteristic  of  eclampsia.  Paroxysms  of  hysteria  ordi- 
narily begin  with  sobs,  a feeling  of  constriction  at  the  throat,  and  they 
consist  in  violent  movements  of  the  body,  they  terminate  in  weep- 
ing, and  in  loud  cries,  but  without  frothing  of  the  mouth,  change  of 
the  countenance,  or  stupor.  Cataleptic  attacks  are  marked  by  mus- 
cular rigidity,  without  any  convulsive  motions,  without  consecutive 
stupor,  or  any  disorder  of  the  understanding  after  the  attack.  More- 
over, catalepsy  is  more  common  in  pregnancy  than  in  labour,  during 
which  it  is  suspended ; besides,  it  compromises  neither  the  mother 
nor  the  child.  Attacks  of  tetanus  are  signalized  by  painful  and  per- 
manent muscular  rigidity  of  one  or  more  parts  or  of  the  whole  sys- 
tem, but  without  alteration  of  the  intellectual  or  sensorial  powers. 
These  attacks  are  extremely  rare  in  labour,  only  one  woman  having 
been  seen  to  perish  with  it. 

Epilepsy  is  the  disease  that  bears  the  closest  resemblance  to 
eclampsia;  indeed,  there  is  no  difference  between  them  except  in 
the  closing  of  the  paroxysm.  In  eclampsia  the  stupor  is  much  more 
decided  and  lasting.  Besides,  the  pregnant  state,  and  the  non-exist- 
ence of  epilepsy  previous  to  the  conception,  which  generally  suspends 
an  epilepsy,  are  circumstances  that  show  the  case  to  be  one  of  eclamp- 
sia. The  eclarnpsic  stupor,  moreover,  should  not  be  confounded 
with  apoplexy,  which  is  not  ushered  in  with  convulsion,  and  is 
attended  by  a persistent  paralysis.  Let  us  further  add  that  it  is 


puerperal  convulsions. 


639 


quite  as  easy  to  distinguish  the  puerperal  convulsion  from  those  that 
follow  violent  flooding. 

The  treatment  of  eclampsia  should  be  modified  accordingly  as  the 
attack  takes  place  during  the  progress  of  the  pregnancy,  coincidently 
with  labour,  or  after  the  birth  of  the  child. 

During  pregnancy . Should  the  physician  arrive  during  an  attack, 
instead  of  remaining  a passive  spectator  of  the  scene,  he  should  see 
that  the  patient  be  properly  held  by  intelligent  assistants,  so  as  not 
to  repress  her  movements  too  much;  then  when  the  mouth  opens 
and  shuts  with  violent  force  he  ought  to  push  the  tongue,  whenever 
it  is  thrust  forth,  back  into  the  mouth,  and  retain  it  there  with  his 
fingers,  lest  it  might  be  seriously  lacerated.  For  fear  of  being  bitten, 
a piece  of  fine  cork  might  be  made  use  of  for  this  purpose ; but  a 
spoon  ought  never  to  be  introduced  into  the  mouth,  as  is  done  by 
most  physicians.  It  is  proper,  also,  to  compress  the  carotids,  and  to 
pour  cold  water  on  the  face,  especially  if  the  attendant  be  present 
during  the  prodromes  of  a paroxysm,  to  which,  also,  he  ought  to 
oppose  a venesection,  and  leeches  to  the  throat,  the  temples  and  epi- 
gastrium, which  is  in  general  the  seat  of  some  disease. 

But  it  is  particularly  after  the  attack  is  over  that  the  physician 
may  act  with  the  greatest  advantage.  Blood-letting  is  proper  in  true 
eclampsia,  not  only  where  the  patient  is  plethoric,  but  also  in  those 
who  are  infiltrated,  with  this  difference,  however,  that  it  should  be 
more  abundant  in  the  former  sort.  Bleeding  from  the  arm  is  always 
to  be  preferred  to  bleeding  from  the  jugular  vein  or  the  temporal 
artery,  for  these  require  a subsequent  compression  that  obstructs  the 
return  of  the  circulation;  it  is  also  to  be  preferred  to  bleeding  in  the 
foot,  which  is  generally  impracticable,  on  account  of  the  infiltration 
of  the  lower  extremities.  The  quantity  of  blood  to  be  taken  away 
is  from  twenty  to  forty  ounces,  twenty-five  to  thirty  for  the  mean, 
twenty  for  the  minimum,  and  forty  as  the  maximum  quantity.  Al- 
though Hamilton  and  Dewees  carry  the  quantity  to  be  withdrawn 
up  to  fifty,  and  even  to  one  hundred  ounces,  the  quantity  we  have  in- 
dicated ought  rarely  to  be  exceeded.  Should  the  symptoms  not  be 
lessened,  the  bleeding  might  be  repeated  a second,  or  even  a third 
time  in  the  course  of  the  day  ; but  these  abstractions  of  blood  should 
be  much  more  limited  than  the  first  one.  Abstraction  of  blood  by 
leeches  to  the  nucha,  the  throat,  and  the  temples,  will  also  be  useful ; 
yet  they  should  be  had  recourse  to  only  as  an  auxiliary  measure,  and 
as  substitutes  for  a second  or  third  general  bleeding,  but  never  as  a 

PRIMARY  MEASURE. 

It  is  useful  to  associate  with  the  venesection  the  use  of  derivatives 
to  the  intestinal  canal,  by  means  of  mild  cathartics,  such  as  castor 
oil,  calomel,  alone  or  in  combination  with  jalap,  in  a dose  of  from 
five  to  ten  grains,  and  also  the  sulphate  of  soda  or  of  magnesia. 
Mauriceau  used  senna  with  the  juice  of  an  orange;  Delamotte 
recommended  rhubarb,  manna,  the  syrup  of  nerprun , and  Merri- 
man  prescribed  a pill  of  five  grains  of  calomel,  followed  by  a solu- 
tion of  some  purgative  salt,  the  doses  being  repeated  every  third  or 
fourth  hour, the  operation  being  solicited  by  laxative  enemata.  Should 


640 


PUERPERAL  CONVULSIONS. 


the  stupor  be  so  great  as  to  hinder  the  opening  of  the  mouth,  these 
purgatives  ought  to  be  administered  by  injection.  Emetics  ought 
not  to  be  prescribed  except  where  the  attack  should  coincide  with  an 
overloaded  stomach,  or  where  the  disorder  seems  to  have  some  con- 
nection with  gastric  derangement. 

Derivative  applications  to  the  skin  appear  to  be  not  less  beneficial 
than  the  other  measures  of  relief;  but  their  employment  ought  to  be 
wisely  managed.  We  should  confine  ourselves  to  the  application  of 
warm  cataplasms  to  the  feet  and  legs,  where  the  attacks  are  fre- 
quently repeated ; but  in  case  the  convulsions  return  at  intervals  of 
several  hours,  sinapisms  may  be  advantageously  placed  on  the  legs 
and  blisters  to  the  inside  of  the  thighs  and  to  the  nape  of  the  neck. 
These  counter-irritants  are  most  especially  useful  where  the  stupor  is 
of  long  duration ; but  the  blisters  ought  to  be  removed  as  soon  as 
the  rubefacient  effect  shall  have  been  produced. 

Cold  applications  to  the  head,  such  as  ice  or  cold  water  in  a blad- 
der, may  likewise  be  very  useful.  Under  such  circumstances  we 
ought  not  to  hesitate  to  cut  off  the  hair.  Should  the  stupor  be  per- 
sistent and  more  decided,  care  ought  to  be  taken  to  remove  the  cold 
applications.  Let  us  add,  that  Merriman  recommends  the  following 
mixture : — 

R. — Liquid  acetate  of  Ammonia,  3iv 

Spirit  of  Rosemary,  3ij. 

Water,  3j. 

Mix. 

Baths,  also,  afford  a very  useful  remedy ; but  they  are  suitable  only 
in  cases  where  the  paroxysms  are  separated  by  considerable  intervals, 
during  which  the  patient  recovers  her  senses.  Tepid  baths  are  par- 
ticularly valuable  as  remedies  in  this  case,  where  care  is  taken  to 
direct  cold  aspersions  to  the  head,  or  to  keep  a bladder  of  ice  upon 
it ; they  are  injurious  if  the  convulsions  are  frequent,  and  the  stupor 
very  great.  It  would  be  useful,  in  such  a case,  to  introduce  the 
catheter  and  empty  the  bladder,  whose  excessive  distension,  and  the 
suppression  of  urine,  which  are  common  occurrences  during  the 
stupor,  might  tend  to  excite  renewed  attacks  of  the  convulsion. 

The  antispasmodics,  as  opium,  musk,  assafoetida,  camphor,  &c.,  the 
effect  of  which  is  slow,  will  not  often  be  resorted  to  in  this  form  of 
convulsions;  opium  especially  should  be  made  use  of  only  with  great 
reserve,  when  there  is  cerebral  congestion  and  stupor ; nevertheless, 
Dr.  Collins,  of  Dublin,  informs  us  that  he  met  with  great  success  in 
the  use  of  this  article  combined  with  emetic  tartar,  which,  after  pre- 
mising the  other  remedies,  he  prescribed  as  follows : — 

R. — Water,  3viij. 

Tartar  Emetic,  gr.  viij. 

Tincture  of  Opium,  Tltxxx. 

Syrup,  3ij. 

Mix. 

To  be  taken  in  doses  of  a tablespoonful  every  half-hour.  M.  Vel- 
peau, also,  asserts  that  he  was  successful  in  the  use  of  acetate  of 
morphia,  in  doses  of  a quarter  or  half  grain  every  second  or  third 


PUERPERAL  CONVULSIONS. 


641 


hour,  mixing  it  in  a tablespoonful  of  water.  We  believe  that  the 
sedative  remedies  have  been  useful  chiefly  in  cases  other  than 
eclampsia. 

[I  am  much  pleased  with  M.  Colombat’s  bold  and  vigorous  employment 
of  the  lancet  in  his  cases  of  puerperal  eclampsia,  and  perhaps  he  has  gone 
far  enough  in  his  recommendation  of  venesection.  Yet  the  late  Dr.  De  wees, 
Dr.  Chapman  and  most  of  the  practitioners  here,  would  scarcely  feel  them- 
selves warranted,  in  a young,  vigorous  female  in  convulsions,  if  in  a first 
pregnancy,  to  take  less  than  forty  to  sixty  ounces  of  blood,  provided  the 
repetition  of  the  attacks  should  serve  to  show  that  the  hyperaemic  state  of 
the  brain,  leading  to  the  first  convulsion,  was  not  overcome  by  the  first 
bleeding  of  twenty  or  thirty  ounces. 

I am  not  so  well  satisfied  as  to  his  abjuration  of  opium  in  the  treatment. 
I believe  it  has  become  a very  general  practice  here,  to  give  opium  freely  in 
almost  all  the  cases  where  full  blood-letting  has  been  premised,  and  after  the 
unloading  of  the  bowels  by  very  active  enemata.  I should  make  it  almost 
invariably  a rule,  to  give  from  twenty  to  forty  drops  of  laudanum,  to  be 
repeated  even  several  times,  and  at  no  very  distant  points  of  time,  where  I 
could  no  longer  entertain  any  doubts  as  to  whether  I had  been  sufficiently 
attentive  to  relieve  the  brain  by  free  use  of  the  lancet,  and  of  cups  or 
leeches.  It  appears  to  me,  that  I have  seen  several  women  pass  gradu- 
ally from  the  stupor  or  coma  of  eclampsia  into  the  quietest  sleep  under  the 
soporific  and  anodyne  power  of  opium — a practice  that  has  proved  not 
only  safe  but  most  efficacious.  Indeed,  the  nervous  excitability  left  after 
the  convulsion,  the  labour,  the  blood-letting  and  other  treatment,  seems 
loudly  to  call  for  the  hypnotic  power  of  this  most  beneficent  drug.  It  is 
quite  true,  that  a treatment  undertaken  without  reference  to  the  predis- 
posing causes  and  influences  might  lead  the  practitioner  to  be  too  soon 
satisfied  with  his  prescription  of  venesection,  and  permit  him  to  hasten  the 
exhibition  of  the  opiate  sooner  than  the  state  of  the  patient  would  really 
warrant.  If  we  reflect  but  a moment  upon  the  facts,  we  shall  be  com- 
pelled to  admit  that  puerperal  convulsion  is  far  more  common  in  primi- 
parous  women  than  in  women  who  have  already  undergone  the  fatigues 
and  excitements  of  gestation  and  labour.  But  why  should  this  be  the 
case,  seeing  that  the  health  and  strength  of  the  patient  should  be,  cseteris 
paribus,  better  than  that  of  the  woman  who  has  already  been  racked  with 
the  pains  and  all  the  accidence  of  the  gestative  and  parturient  state  ? Iam 
fully  of  the  opinion  set  forth  by  Puzos,  at  p.  173  of  the  Traite  ties  Re- 
concilements, who  says:  “If  the  blood-lettings  and  other  remedies  do  not 
calm  the  convulsions,  and  should  they,  on  the  contrary,  become  more  fre- 
quent, the  measure  most  indispensable  is  to  deliver  the  woman  as  soon  as 
possible ; for,  by  freeing  the  womb  of  such  a burthen,  we  emulge  the  great 
vessels  that  run  along  the  course  of  the  spine,  and  allow  the  blood  to  flow 
equally  to  every  part,  whereas,  before  the  delivery,  the  excessive  pressure 
41 


642 


PUERPERAL  CONVULSIONS. 


of  the  child  upon  the  great  trunks  of  the  descending  aorta,  compelled  the 
blood  to  flow  upwards  to  the  superior  parts  and  to  inundate,  so  to  speak, 
the  mass  of  the  brain.” 

This  sentiment  of  Mons.  Puzos  has  been  reiterated  by  writers,  but  it 
appears  to  be  one  so  just  and  apposite,  that  proper  occasion  ought  always 
to  be  taken  to  enforce  it  and  promulgate  it.  The  strong,  healthful,  resisting 
muscles  of  the  woman  who  has  not  borne  children,  cannot  fail  to  compress 
the  womb  with  considerable  more  force  than  the  weak,  flaccid  muscles  of  the 
female  who  has  been  already  confined.  Under  such  compression  the  blood 
tends  to  accumulate  in  the  head  and  superior  extremities,  and  to  develop 
there  a more  active  and  powerful  nutrition.  In  many  such  the  hands  are 
swollen  and  stiff  upon  rising  in  the  morning,  and  the  face  becomes  bloated 
or  swelled — the  old  notion,  that  a woman  who  has  conceived  cannot  measure 
the  circumference  of  her  neck  with  a thread  that  was  quite  long  enough  to 
go  round  it  before,  has  some  foundation  in  fact,  then. 

Non  illam  nutrix,  oriente  sole  revisens 

Hesterno  poterit  circumdare  collum  filo. 

The  rapid  development  of  the  mammae  in  pregnancy  is  also,  in  part,  attri- 
butable to  the  inundation  of  the  superior  parts  of  the  body  with  the  blood,  the 
source,  the  cytoblastem  of  all  nutritive  absorption.  In  primiparous  females, 
then,  the  brain,  ipso facto , is  to  be  held  as  in  a hyperaemic  state  for  some  weeks, 
or  even  months  before  the  commencement  of  the  labour.  Let  the  labour- 
pains  be  violent,  long  ones  and  for  a long  time  repeated — how  can  it  happen, 
that  the  solid,  contracted  globe  of  the  womb  shall  be  pressed  violently  and 
repeatedly  against  the  descending  trunk  of  the  aorta,  without  more  or  less 
impeding  the  flow  of  blood  in  the  tube,  and,  consequently,  compelling  the 
carotids  a!nd  superior  branches  to  carry  a preternatural  quantity.  This  ex- 
cessive sanguine  determination,  which  so  frightfully  engorges  the  face  and 
bosom  of  the  female  in  her  throes,  is  generally  rendered  harmless  by  the 
floods  of  perspiration  which  deluge  the  superior  parts,  while  the  legs  and 
feet  remain  dry.  The  salutary  diversion  thus  effected,  saves  many  women 
from  apoplexy  and  from  eclampsia.  I look  upon  it  as  a dangerous  state, 
when  a woman  in  strong  labour  does  not  sweat  freely  from  the  head  and 
thorax.  She  is  generally  in  danger  of  convulsion. 

It  is  with  me  a rule,  not  to  allow  a primiparous  female  to  lie  long  upon 
her  back  while  in  strong  labour,  for  fear  that  the  weight  of  the  womb  super- 
added  to  the  pressure  of  the  abdominal  muscles,  might  check  the  aortic  cir- 
culation too  considerably — and  the  more  particularly  would  I forbid  a dorsal 
decubitus  in  case  she  should  make  any  complaint  of  headache,  dizziness, 
flashings  of  light,  or  tinnitus,  or  manifest  any  other  symptoms  of  excessive 
sanguine  determination  to  the  head. 

M.  Velpeau,  in  his  monograph  on  puerperal  convulsions,  speaks  of  the 
value  of  blood-letting  as  inestimable  in  the  treatment  of  the  malady,  and  yet 
admits  that  the  most  eradicative  abstractions  will  not  suffice  in  all  cases  to 


PUERPERAL  CONVULSIONS. 


643 


secure  the  patient’s  recovery.  So,  likewise,  Dr.  Robt.  Lee  [Led.  on  the 
Theory  and  Pract.  of  Mid .,  p.  400)  advises,  in  energetic  terms,  the  use  of 
the  lancet:  “Copious  blood-letting  in  puerperal  convulsions  is  the  first 
remedy  now  employed  by  all  practitioners  in  this  country,”  [loc.  cit.,) 
and,  though  he  admits  the  impracticability  in  some  cases,  to  abstract  a suffi- 
cient quantity  to  save  the  patient,  he  evidently  looks  upon  it  as  the  sheet- 
anchor  of  hope. 

I need  not  extend  this  note  for  the  purpose  of  reiterating  directions  as  to 
enemata,  cathartics,  cups,  leeches  and  sinapisms,  shaving  the  head,  &c.  • 
these  are  too  obvious  to  require  any  notice  from  me,  but  I desire  to  say, 
that  the  practice  here  at  present  is,  so  far  as  I know,  nearly  universal,  to 
give  full  doses  of  opium  as  soon  as  the  practitioner  is  satisfied  that  he  has 
carried  his  venesections  to  a sufficient  extent.  Robt.  Lee,  loc.  cit.,  says : 
“Opium  has  been  almost  universally  condemned  in  puerperal  convulsions, 
and  I consider  it  improper  before  blood-letting  has  been  employed  to  a suffi- 
cient extent,  and  delivery  has  been  completed,  either  spontaneously  or  arti- 
ficially. In  some  of  the  most  severe  cases  which  I have  seen,  after  copious 
venesection  and  delivery,  large  doses  of  the  liquor  opii  seditivus,  have  ap- 
peared to  produce  very  powerful  effects  in  arresting  the  fits ; in  others,  no 
benefit  whatever  resulted  from  the  employment  of  sedatives  of  any  kind,” 
402.  The  caution  of  the  distinguished  writer,  as  to  the  exhibition  of 
opium  before  delivery,  is,  I think,  a case  of  excessive  caution,  since  I have 
seen  women  recover,  undelivered,  under  very  liberal  exhibitions  of  opium  ; 
but  never  until  the  venesections  had  been  carried  to  a great  extent.  Indeed, 
I do  not  perceive  that  delivery  or  non-delivery  has  any  thing  to  do  with  the 
therapeutical  principle  of  the  case,  as  to  the  exhibition  of  the  drug. 

M.  Colombat  coincides  with  every  body  in  the  opinion,  that  the  brain, 
when  examined  after  death,  generally  yields  no  pathological  lesions  to 
explain  the  violence  of  the  disorder.  We  have  a legitimate  right  then  to 
infer,  that  the  disorder  is  one  of  extreme  cerebral  excitement  from  hyperse- 
mia,  and  from  sympathy  of  the  brain  with  the  irritated  organs  below. — 
What  could  then  be  more  reasonable  than  the  exhibition,  after  abundant 
depletion  and  evacuation,  of  full  doses  of  the  anodyne,  the  only  one  that 
can  be  expected  to  remove  from  the  encephalon  its  excessive  perceptivity 
of  distant  irritations. — M.] 

If  it  be  agreed  that  the  state  of  plenitude  of  the  uterus,  is  one  of 
the  most  powerful  causes  of  the  eclampsic  convulsion,  does  it  not 
appear  to  be  reasonable  to  arrest  those  convulsions  by  emptying  the 
womb?  When  the  attacks  come  on  before  the  sixth  month,  we  ought 
to  make  every  effort  to  overcome  them,  without  provoking  delivery; 
but  there  is  no  necessity  for  such  precautions  where  the  viability  of 
the  foetus  is  already  possible,  that  is,  where  the  pregnancy  has  nearly 
reached  its  term,  and  especially  where  the  cervix  is  soft  and  dilata- 
ble, and  where  the  attacks,  after  resisting  the  venesections,  baths,  &c., 
threaten  to  prove  speedily  fatal.  Under  circumstances  like  these  we 


644 


PUERPERAL  CONVULSIONS. 


should  be  justified  in  rupturing  the  membranes,  or  detaching  them, 
and  should  those  steps  fail,  we  could  properly  proceed  to  a forced 
premature,  delivery.  It  is  true  that  cases  where  such  measures  are 
required  are  very  rare ; they  would  be  useful  only  in  women  who 
have  already  borne  children,  and  not  in  cases  of  primiparous  women, 
who  are  precisely  those  most  liable  to  puerperal  convulsions,  and  in 
whom  the  os  uteri  is  almost  always  rigid  and  not  readily  dilatable. 
In  fine,  where  the  paroxysms  are  very  violent,  they  commonly  excite 
uterine  contractions,  which  often  effect  the  expulsion  of  the  child. 
Besides,  we  must  never  despair  of  seeing  the  attacks  disappear, 
never  to  return,  allowing  the  woman  to  come  to  her  bed  without 
any  disaster. 

During  the  labour  the  assistance  of  art  may  be  demanded,  either 
when  the  os  uteri  is  undilated,  or  where  the  dilatation  is  completed. 
In  the  former  case,  after  the  employment  of  the  measures  now  pointed 
out,  them  is  a better  chance  of  success,  the  pregnancy  being  at  term, 
by  resorting  to  the  means  proper  to  facilitate  the  natural  expulsion, 
or  even  to  terminate  the  delivery  artificially.  In  order  to  assist  the 
natural  delivery  we  should  order  emollient  fumigations  by  means  of 
a funnel,  the  nozzle  of  which  being  covered  with  a piece  of  linen, 
should  be  directed  towards  the  womb;  by  injections  of  the  same 
kind ; by  the  employment  of  belladonna  mixed,  in  equal  parts,  with 
cerate,  or  pure  in  the  form  of  extract,  say  two  or  three  grains,  which 
should  be  placed  on  the  os  uteri  by  the  index  finger.  But  prudence 
is  necessary  here,  for  the  drug  being  promptly  absorbed,  might  prove 
dangerous  in  the  convulsions,  particularly,  were  the  coma  very  much 
prolonged.  The  introduction  of  the  fingers  with  the  design  to  dilate 
the  os  uteri,  ought  not  to  be  considered  proper  in  the  major  part  of  the 
cases;  for  the  irritation  it  excites  provokes  to  repetition  of  the  pains 
at  improper  intervals,  and  thereby  tends  to  bring  on  attacks  of  con- 
vulsion. The  same  principle  applies  to  the  administration  of  the 
spurred  eye,  the  action  of  which  is  not  to  be  doubted  of,  but  which, 
by  bringing  on  powerful  and  permanent  contractions,  might  probably 
give  rise  to  the  eclampsic  paroxysm.  However,  the  use  of  this 
remedy  might  be  resorted  to  in  desperate  cases. 

The  measures  now  indicated  having  been  put  in  execution  without 
any  happy  effect,  and  the  convulsions  increasing  in  frequency  and 
violence,  in  such  a way  as  clearly  to  compromise  the  lives  both  of 
the  mother  and  her  child,  the  practitioner  should  endeavour  to  con- 
clude the  labour  by  rupturing  the  membranes  by  means  of  a catheter, 
by  incising  the  os  uteri,  or  by  turning  the  child  and  delivering  it  foot- 
ling. There  are  cases  that  go  to  show  the  advantage  of  rupturing 
the  membranes,  where  dilatation  has  already  commenced,  and  where 
the  excessive  distension  of  the  uterus  appears  to  act  as  a cause  of  the 
obstinacy  of  the  attacks,  and  especially  where  the  presentation  of  the 
foetus  is  natural  and  favourable.  It  ought  not  to  be  done,  however, 
under  opposite  circumstances;  for  it  might  then  be  followed  by  the  loss 
of  the  child,  from  pressure  on  the  umbilical  cord,  or  it  might  render  the 
delivery  by  any  manual  or  instrumental  operation,  far  more  difficult. 
Were  the  os  uteri  somewhat  open,  soft  and  very  dilatable,  we  should 


PUERPERAL  CONVULSIONS. 


645 


be  justified  in  resorting  to  compulsory  delivery  by  the  hand,  which 
is  passed  up  to  the  child’s  feet,  which  are  brought  down  until  the 
child  is  completely  turned,  and  so  delivered.  But  the  time  required 
for  this  operation,  and  the  pain  it  gives,  appear  to  us  reasons  for  pre- 
ferring the  incision  of  the  os  uteri,  which  gives  occasion  to  less  lacera- 
tion, less  pain,  and  fewer  accidents  of  any  sort  than  forced  delivery 
by  turning.  This  operation,  proposed  by  Simson  and  Lauverjeat, 
under  the  title  of  vaginal  Caesarian  operation,  is  done  with  a probe- 
pointed  bistoury  that  should  be  a little  falciform.  The  blade,  applied 
flat  along  the  finger,  should  be  carried  up  to  the  cervix  and  applied 
to  the  anterior  margin  of  the  circle  of  the  os  uteri,  which  should  be 
then  cut  or  divided  by  a forward  movement  of  the  bistoury.  One 
incision  might,  perhaps,  prove  sufficient,  but  it  is  better  to  make  twc 
or  three  of  them  of  a smaller  size.  Such  an  operation  as  this,  be  it 
understood,  ought  not  to  be  ventured  upon,  as  long  as  there  is  any 
other  chance  of  success  in  the  treatment.  For  the  most  part,  after 
this  chirurgical  relaxation  of  the  cervix,  nature  provides  for  the  deli- 
very^— where  her  power  proves  incompetent,  it  is  our  business  to 
bring  it  to  a conclusion. 

In  cases  where  convulsions  come  on  at  an  advanced  stage  of  la- 
bour, there  ought  to  be  no  hesitation  about  terminating  the  labour  by 
turning,  should  not  the  head  be  sufficiently  engaged  in  the  superior 
strait  of  the  pelvis ; in  other  circumstances,  we  should  make  use  of 
the  forceps,  which  is  fraught  with  less  danger  to  the  mother  than  the 
version  delivery.  Where  the  attack  of  convulsion  comes  on  after 
the  woman  is  delivered  of  the  child,  the  prime  indication  would  be 
to  remove  the  placenta  and  free  the  womb  from  any  coagula  that 
might  be  found  within  its  cavity;  should  the  attacks  still  come  on, 
we  ought  to  have  recourse  to  blood-letting,  to  counter-irritants,  to 
baths,  to  cataplasms  to  the  abdomen,  to  emollient  and  detergent 
injections ; and  in  a case  where  a flooding  should  threaten  to  pro- 
duce an  eclampsic  attack,  it  should  be  checked  by  cold  astringent 
applications  to  the  hypogastrium,  and  even  by  the  tampon,  should 
the  measures  first  recommended  fail  of  success. 

[It  is  difficult  for  us  to  imagine  a haemorrhage  as  menacing  the  woman 
with  puerperal  convulsions,  as  M.  Colombat  appears  to  suppose  it  might  do. 
On  the  contrary,  every  additional  ounce  of  blood  that  should  drain  off  from 
the  body  might  be  expected  to  relieve  the  brain  of  its  sanguine  or  hyperae- 
mic  determination.  It  is  true  that  haemorrhage,  when  excessive  and  on  the 
point  of  proving  fatal,  brings  upon  the  patient  a short,  quick,  rapid  convul- 
sion, but  such  a convulsion  is  free  from  the  very  nature  and  character  of  the 
eclampsia.  I protest  likewise  against  the  author’s  doctrine  as  to  the  arrest 
of  the  supposed  haemorrhage  by  the  tampon;  that  is,  as  a proposition  per 
se,  without  those  modifications  of  precept  which  ought  to  accompany  all 
directions  as  to  the  use  of  the  tampon.  I have  had  so  many  and  such  vexa- 
tious occasions  to  remember  of  tampons  consisting  of  coagula  of  blood  in 
the  vagina,  which  I always  make  haste  to  turn  out,  that  I feel  little  inclined 
to  pass  over  an  unmitigated  prescription  of  so  dangerous  a remedy. 


646 


PUERPERAL  CONVULSIONS. FALLING. 


When  a woman  is  not  yet  delivered,  a tampon  can  in  general  only  serve 
to  enhance  any  danger  from  the  haemorrhage,  on  account  of  which  it  is  em- 
ployed, and  that,  by  blocking  up  the  blood  that  continues  to  pour  from  the 
uncovered  vascular  orifices  in  the  womb,  until  the  cavity  of  the  uterus  be- 
coming filled,  it  gradually  yields  to  the  pressure,  and  dilates  more  and  more. 
As  the  superficies  of  the  uterus  augments,  the  patulous  orifices  of  the  vessels 
become  more  and  more  open,  and  the  torrent  of  effusion  becomes  greater 
and  greater ; so  rapidly,  indeed,  that  many  women  have  bled  and  died  with- 
out discharging  any  considerable  quantity  from  the  vulva.  The  tampon 
cannot  save  a woman  by  causing  the  blood  to  coagulate — nor  can  it  return 
into  the  veins  the  fluid  already  extravasated.  When  blood  is  once  out  of 
the  vessel,  it  should  get  out  of  the  body  as  soon  as  practicable — and  the 
woman’s  safety  can  only  be  considered  as  absolute,  when  it  is  procured  by 
means  of  a firm  contraction  and  condensation  of  the  womb.  I agree  with 
Robt.  Lee,  who  says  in  his  Clinical  Midwifery , that  upon  the  whole,  the 
tampon,  even  as  used  in  the  cases  of  placenta  praevia  under  his  care,  has 
done  as  much  harm  as  good. — M.] 

In  fine,  should  the  mother  have  breathed  her  last  during  the  pro- 
gress of  the  labour,  the  Caesarian  operation  ought  to  be  performed, 
notwithstanding  the  slight  chance  of  success  in  such  an  attempt  to 
rescue  the  life  of  the  child.  We  remark  further,  that  an  attack  of 
eclampsia  might  often  be  obviated  by  a preventive  treatment,  con- 
sisting of  venesection,  baths  and  purgative  medicines,  which  would  be 
indicated  in  cases  of  women  infiltrated,  or  suffering  under  cephalal- 
gia, disordered  vision,  vertigo  and  other  significant  symptoms.  As  to 
attacks  of  hysterical  convulsion,  of  an  hysterical,  cataleptic  or  tetanic 
character,  which  are  almost  always  innocuous  as  to  the  female,  as 
well  as  to  the  child,  they  should  be  combatted  by  means  of  blood- 
letting, particularly  where  the  patient  is  plethoric,  and  by  antispas- 
modics  and  derivatives,  taking  great  care  always  to  follow  out  the 
true  indication  as  it  may  be  developed. 

DISPOSITION  TO  FALL. 

It  is  undeniable  that  pregnant  women  are  much  more  liable  to  fall 
than  non-gravid  females;  this  peculiarity  may  depend  upon  the  great 
prominence  of  the  abdomen,  preventing  the  person  from  seeing  the 
stumbling-blocks  that  lie  in  her  path,  or  upon  the  reversed  position 
she  is  obliged  to  take  in  order  to  keep  up  her  equilibrium,  or,  indeed, 
upon  the  rapid  increase  of  the  weight  of  the  body,  and  the  unfa- 
vourable distribution  of  that  weight.  It  has,  likewise,  been  supposed 
that  the  pressure  of  the  womb  upon  the  crural  and  sciatic  nerves 
gives  rise  to  a debility  and  sort  of  incomplete  paralysis  of  the  inferior 
extremities. 

These  falls,  which  are  both  frequent  and  dangerous  in  the  gravid 
female,  are,  however,  much  less  common  among  countrywomen, 
who  retain  their  strength  and  activity  better  than  the  women  of 
large  cities  do;  it  is  true,  however,  that  these  accidents  are  much 


DISORDERS  OF  THE  URINARY  ORGANS. 


647 


more  rare  than  they  were  before  the  absurd  and  ridiculous  fashion 
of  wearing  narrow  high-heeled  shoes  was  abandoned.  All  we  can 
do  is  to  advise  our  patients  to  be  doubly  careful  of  their  gait,  so  as  to 
lessen,  as  far  as  practicable,  the  awkwardness  concomitant  on  the 
pregnant  state. 

DISORDERS  OF  THE  URINARY  ORGANS  DURING  GESTATION. 

Situated  betwixt  the  pubes  and  the  womb,  the  urinary  bladder 
undergoes  several  modifications  during  pregnancy.  Being  more  and 
more  compressed  as  the  womb  augments  in  size,  its  expansion  is 
obstructed,  whence  arises  a necessity  frequently  to  discharge  the 
urine.  When  the  pressure  acts  on  the  neck  of  the  bladder  and  the 
meatus  urinarius,  ardor  urines  will  follow,  and  strangury  likewise, 
should  the  pressure  by  the  womb  irritate  the  mucous  membrane  of 
the  parts,  and  excite  any  inflammation  of  the  tissue. 

These  disagreeable  effects  of  the  pressure  of  the  womb  on  the  blad- 
der are  met  with,  chiefly,  at  two  periods.  First,  betwixt  the  fourth 
and  the  fifth  month,  especially  where  the  pelvis  is  spacious  enough 
to  allow  the  womb  to  remain  within  it  after  the  period  mentioned ; 
next,  during  the  three  last  months  of  pregnancy,  especially  in  women 
with  decided  anterior  obliquity  of  the  uterus,  allowing  it  after  rising 
above  the  plane  of  the  superior  strait,  to  compress  the  body  of  the 
bladder  against  the  anterior  parietes  of  the  abdomen,  or  the  neck  of 
the  bladder  against  the  posterior  surface  of  the  symphysis  pubis. 
The  bladder  is  then  drawn  along  by  the  womb,  which  is  attached  to 
it  by  the  utero-vesical  septum,  whence  it  happens  that  the  neck  of  the 
bladder  is  bent  like  a retort,  making  it  impracticable  to  introduce 
the  catheter,  except  with  a sound  very  much  curved,  like  those  used 
for  the  male  urethra.  Under  such  circumstances  the  affection  con- 
tinues until  after  the  accouchement  of  the  patient,  whereas,  in  the 
first-mentioned  sort,  it  ceases  as  soon  as  the  uterus  rises  above  the 
strait. 

Dysuria  and  strangury  may  also  depend  upon  a degree  of  dis- 
placement of  the  womb,  especially  upon  a retro  verted  position  of  the 
organ ; upon  a calculus  in  the  bladder,  or  on  a catarrhal  inflamma- 
tion, or  on  inflammation  produced  by  haemorrhoids.  These  diseases, 
whose  chief  symptom  is  retention  of  the  urine,  demand  a peculiar 
treatment,  to  which  it  is  urgently  necessary  to  have  recourse  as  early 
as  possible,  for  the  excessive  distension  of  the  bladder  might  lead, 
not  to  its  inflammation  only,  but  to  its  absolute  rupture. 

A retention  of  urine  occasioned  by  compression  from  a womb  that 
has  become  too  voluminous,  is  developed  gradually,  unless,  indeed, 
some  error  of  regimen  should  happen  to  impart  to  it  a suddenly  violent 
intensity.  In  all  sorts  of  cases  there  are  two  principal  indications  to 
be  taken  up  ; one  of  which  consists  in  promptly  evacuating  the  blad- 
der, and  the  other  is  to  hinder,  as  far  as  possible,  the  accumulation 
of  fluid  in  its  cavity.  For  the  fulfilment  of  the  first  indication,  a 
curved  catheter  should  be  used,  after  which  the  faulty  position  of  the 
womb,  giving  rise  to  the  suppression,  ought  to  be  corrected.  The 


648 


DYSURIA. VARIOUS  PAINFUL  AFFECTIONS. 


employment  of  these  measures  may  be  always  usefully  preceded  by 
the  warm  bath,  by  emollient  fomentations,  and  even  by  venesection, 
provided  the  early  remedies  should  have  been  deferred. 

To  fulfil  the  second  indication,  which  consists  in  repositing  and 
supporting  the  uterus,  all  that  is  requisite  is  to  raise  the  womb  up- 
wards by  the  hands  placed  on  the  abdomen,  or  likewise  to  bend  the 
body  very  strongly  forwards,  so  that  the  womb  may  be  got  out  of  the 
superior  strait.  Where  these  attempts  fail,  we  may  readily  obtain 
the  discharge  of  the  urine  by  lifting  the  uterus  upwards  by  one  or 
two  of  the  fingers  introduced  within  the  vagina.  The  woman  her- 
self should  be  taught  to  effect  this  purpose  for  herself.  Further,  the 
effects  of  the  uterine  pressure  may  be  lessened  by  keeping  the  patient 
in  a horizontal  posture,  and  by  the  use  of  a binder  with  which  to 
support  the  abdomen.  Where  the  difficulty  of  passing  the  urine 
depends  upon  hsemorrhoidal  swellings,  leeches  ought  to  be  applied 
to  the  anus,  and  the  patient  should  go  into  the  bath,  and  be  after- 
wards kept  perfectly  at  rest. 

A frequent  necessity  to  urinate,  and  even  an  incontinence  of  urine, 
constitute  less  a disease  than  an  inconvenience,  which  besides  is  likely 
to  continue  until  the  delivery  of  the  child,  when  it  cures  itself. 

Notwithstanding  our  art  can  boast  of  but  few  resources  against 
this  affection,  we  can  recommend  demulcent  drinks,  and  emollient 
baths,  to  lessen  the  irritation  of  the  meatus  urinse,  and  to  subdue  the 
sort  of  vesical  tenesmus  that  is  occasionally  conjoined  with  it.  But, 
should  the  incontinence  of  urine  arise  from  atony  of  the  neck  of  the 
bladder,  coming  on  after  strong  compression  by  the  womb,  injections 
ought  to  be  made  with  Barege  waters,  or  the  waters  of  Balarac  or 
Cauterets.  Lastly,  paralysis  of  the  bladder  should  be  combatted  by 
injections  of  soap,  or  Passy- waters,  or  Forges-waters,  or  the  waters 
before  mentioned.  It  seems  proper  to  state  that,  generally  speaking, 
all  the  maladies  of  which  we  have  now  been  speaking  do  not  obtain 
a radical  cure  until  after  the  delivery  of  the  patient,  and  that  all  treat- 
ment up  to  that  consummation  is  therefore  little  else  than  palliative. 

PAINS  IN  DIFFERENT  PARTS  DURING  PREGNANCY. 

Women  at  all  stages  of  pregnancy  are  subject  to  pains  whose  seats 
vary  very  much.  There  are  in  the  early  months  some  women  whose 
breasts,  under  the  sympathetic  influence  of  the  womb,  become  pain- 
ful, and  swollen,  as  happens  at  the  menstrual  periods:  in  others, 
towards  the  conclusion  of  pregnancy,  there  come  on  pains  from  the 
excessive  distension  of  the  skin,  and  from  the  secretion  of  milk  which 
begins  to  take  place.  In  general,  these  pains  require  no  medical 
treatment ; but  in  more  serious  cases,  we  are  compelled  to  combat 
them  by  moderate  warmth,  emollient  cataplasms  sprinkled  with 
laudanum,  and,  above  all,  by  venesection. 

Those  pains  in  the  lumbar  and  sacral  regions  that  women  com- 
plain of  as  backache,  and  which  are  aggravated  by  walking  about 
and  standing  on  the  feet,  may  depend,  perhaps,  on  compression  of 
the  lumbar  or  renal  nerves,  or  the  stretching  of  the  broad  ligaments, 


AFTER-PAINS. 


649 


or,  perhaps,  upon  engorgement  of  the  pelvic  blood-vessels,  or  the 
uterine  vessels,  or  on  the  excessive  distension  of  the  womb.  Pains 
in  the  back  are  also  produced,  in  some  instances,  by  fatigue  of  the 
muscles  of  the  spine. 

We  may  relieve  a patient  of  pain  arising  from  compression  of  the 
lumbar  nerves  or  from  stretching  of  the  ligamenta  lata,  by  rest  and 
the  horizontal  position;  while  such  as  are  dependent  upon  distension 
of  the  womb,  or  plenitude  of  the  pelvic  vessels,  are  subdued  by 
blood-letting.  In  the  former,  the  pains  are  characterized  by  the 
volume,  sensibility  and  tension  of  the  womb  ; in  the  latter,  by  a feel- 
ing of  fulness  at  the  hypogaster,  weight  within  the  pelvis,  and  heat  in 
the  parts,  as  well  as  by  the  signs  of  a general  plethora.  Pains  pro- 
duced by  fatigue  of  the  spinal  muscles,  and  which,  in  addition  to 
their  precise  locality,  are  marked  by  increased  soreness  from  pressure 
on  these  muscles,  generally  give  way  to  alcoholic  and  aromatic  fric- 
tions on  the  parts  affected. 

To  speak  generally,  the  chief  treatment  for  these  pains,  as  well  as 
for  the  cramps  and  numbness  caused  by  Uterine  compression  of  the 
nerves  of  the  sacral  and  lumbar  plexuses,  consists  in  rest,  in  baths, 
opiate  injections,  and  a flannel  bandage  to  support  the  abdomen,  and, 
lastly,  patience,  a remedy  sovereign  in  all  the  disorders  whose  term 
is  almost  always  that  of  the  gestation. 

DISEASES  CONNECTED  WITH  THE  LYING-IN. 

Those  disorders  that  may  follow  the  accouchement  of  the  woman, 
are  situated  either  in  the  organs  of  generation  or  in  any  other  system 
of  the  organism. 

Among  the  former  ought  to  be  classed  lacerations  and  contusions 
of  the  genital  parts,  inversion  of  the  womb  and  vagina,  inflammation 
of  these  organs,  already  treated  of  in  former  chapters,  to  which  we 
refer  the  reader.  The  other  diseases  of  parturition,  most  of  which 
affect  other  systems  of  the  economy,  are,  suppression  of  the  lochia, 
milk-fever,  peritonitis,  uterine  and  crural  phlebitis,  metritis,  phlegma- 
sia dolens,  phlegmonous  abscess,  cutaneous  eruptions,  &c.,  which  we 
shall  proceed  to  treat  of  in  succession. 

AFTER-PAINS. 

The  first  symptoms  that  are  observed  immediately  after  the  deli- 
very of  the  woman  in  labour,  are  the  after-pains  and  the  discharge 
of  the  lochia.  The  after-pains  are  owing  to  the  contractions  of  the 
womb,  and  mainly  occur  whenever  the  cavity  of  the  viscus  is  filled 
with  coagula,  or  with  some  broken  remains  of  the  secundines,  from 
which,  by  this  means,  it  endeavours  to  free  itself.  It  generally  hap- 
pens that  primiparous  women  are  not  affected  with  these  after-pains, 
which  are  found  to  be  more  and  more  violent,  with  each  consecutive 
confinement.  They  are  likewise  more  violent  after  an  easy  labour 
than  after  a long  and  difficult  one.  However,  where  the  parturition 
has  been  extremely  painful,  the  after-pains  are  often  very  distressing, 


650 


AFTER-PAINS. 


in  consequence  of  the  great  fatigue  that  the  womb  has  suffered. 
They  generally  commence  a few  moments  after  the  delivery  of  the 
placenta,  soon  become  more  and  more  intense,  and  then  go  on  les- 
sening in  frequency  and  violence,  until  the  milk-fever  comes  on,  at 
which  period  they  often  disappear  completely.  It  is  proper  to  re- 
mark, however,  that,  in  some  instances,  they  are  prolonged  beyond 
the  term  of  the  milk-fever,  only  diminishing  during  its  existence. 

After-pains  may  be  distinguished  from  other  kinds  of  pain,  by 
their  recurrence  at  considerable  and  regular  intervals,  and  by  observ- 
ing that,  while  they  are  active,  the  uterus  contracts  and  becomes 
hard,  so  as  to  expel  any  clots  along  with  a portion  of  fluid  blood. 
An  after-pain,  moreover,  is  often  brought  on  by  the  pain  that  the 
infant  gives  when  it  seizes  the  nipple.  We  deem  it  scarcely  worth 
while  to  say  any  thing  against  the  ridiculous  prejudice  that  the  more 
griping  the  child  has,  the  less  after-pain  is  to  be  expected  by  the 
mother,  and  vice  versa.  After-pains,  of  sufficient  violence  to  prevent 
the  patient  from  sleeping,  may  be  relieved  by  anodyne  injections, 
enemata  of  tepid  water,  warm  cataplasms  to  the  hypogaster,  or  by  a 
liniment  composed  of  olive  oil  one  ounce,  and  laudanum  one  drachm. 

[The  reader  will  pardon  me  for  here  suggesting  the  necessity  there  is  for 
the  greatest  caution,  in  deciding  what  is,  and  what  is  not,  after-pain.  This 
it  is  not  always  very  easy  to  do,  since,  in  many  women,  the  uterus  remains 
very  sore  and  sensible  to  the  touch,  for  several  days  after  delivery.  Under 
such  circumstances,  the  patient  suffers  extreme  distress,  from  the  frequent 
recurrence  of  the  uterine  contractions,  and,  not  unfrequently,  fever  is  lighted 
up  in  the  system,  as  a reaction  against  the  local  disorder. 

It  is  my  custom,  in  these  cases,  to  take  what  I conceive  the  safest  course, 
viz.,  to  lessen  the  force  of  the  circulation  by  a blood-letting  proportioned 
to  the  exigency.  Certainly,  as  an  anodyne,  or  pain-queller,  the  lancet,  in 
many  circumstances,  transcends  the  efficacy  of  all  other  sedatives. 

I repeat  it,  there  is  great  danger  of  overlooking,  under  a false  security  as 
to  the  diagnosis,  a dangerous  attack  of  metritis.  I am  well  convinced  that 
the  dangerous  attacks  of  metritis  often  coincide  with  what  is  usually  sup- 
posed to  be  merely  violent  after-pain  ; and  I think  it  difficult  to  conceive  of 
pure  after-pain  as  the  sole  pathological  state  of  those  females,  in  whom  the 
after-pains  continue  to  recur,  with  distressing  violence,  during  several  con- 
secutive days,  leaving  the  uterine  globe,  and  the  whole  of  the  hypogastric 
region,  indeed,  very  sensitive  and  sore  to  the  touch.  Even  supposing  that 
such  a stale  can  coincide  with  complete  absence  of  inflammatory  nisus , 
there  is  always  accompanying  it,  a just  ground  to  dread  the  development  of 
some  of  those  disastrous  forms  of  inflammation  to  which  the  uterus  is  held 
always  liable,  and  to  which  it  should  be  regarded  as  excessively  prone, 
under  the  acute  and  irritating  anguish  communicated  by  these  post-puerperal 
contractions.  After-pains  are  well  worthy  of  a careful  supervision. — M.] 


MODIFICATIONS  OF  THE  LOCHIA. 


651 


ACCIDENTS  RELATIVE  TO  THE  LOCHIA. 

Notwithstanding  some  women  have  been  known  to  have  no 
lochia,  and  yet  do  quite  well  in  their  lying-in,  yet  the  absence  of  this 
excretion  is  fit  to  excite  the  solicitude  of  the  accoucheur,  for  it  may 
mostly  be  attributed  to  some  serious  disorder,  either  actual  or  immi- 
nent. Generally  speaking,  the  lochial  discharge  is  most  abundant  in 
women  who  are  in  the  habit  of  menstruating  freely,  in  those  who 
have  had  many  children,  or  who  take  too  nutritious  a diet,  and  like- 
wise in  women  who  do  not  give  suck. 

While  it  is  quite  true  that  the  diminution  of  the  lochial  discharge 
is  ordinarily  the  symptom  of  some  disease,  such  as  peritonitis,  metri- 
tis, &c.,  it  also  happens,  in  some  cases,  that  it  may  be  a primary 
affection,  and  not  the  sympathetic  consequence  of  an  existing  dis- 
order, as  might  be  the  case  after  some  violent  and  sudden  moral 
impression,  the  impression  of  cold  air  upon  the  genital  organs  or  on 
the  lower  extremities,  and  of  ablutions  and  astringent  injections  into 
the  vagina  or  womb  itself.  This  primary  affection  is  most  commonly 
followed  by  the  development  of  very  serious  affections,  such  as 
metritis,  peritonitis,  congestion,  or  nervous  disorders.  All  these  dis- 
orders are  so  much  the  more  dangerous,  and  their  attacks  so  much 
the  more  to  be  dreaded,  in  proportion  as  the  lochia  was  at  first  free, 
and  as  the  suppression  may  have  occurred  at  a period  nearer  to  that 
of  the  recent  delivery.  Sometimes,  also,  it  is  true  that  the  suppres- 
sion is  followed  by  no  bad  consequences,  and  the  health  of  the  woman 
is  not  at  all  affected  by  it,  whether  the  discharges  return  again  fully, 
whether  they  disappear  entirely,  or  whether  they  return  in  a mode- 
rate way. 

The  treatment  of  a primary  suppression  of  the  lochia  consists  in 
the  employment  of  a hot  foot-bath  with  mustard ; in  directing  the 
vapour  of  hot  water  upon  the  sexual  parts ; in  the  application  of 
emollient  cataplasms  to  the  lower  part  of  the  abdomen  and  to  the 
vulva ; in  injections  and  enemata  of  the  same  sort ; and,  lastly,  in 
blood-letting  from  a vein  in  the  foot,  the  application  of  leeches  to 
the  superior  and  inner  portion  of  the  thighs,  or  to  the  inner  surface 
of  the  labia  pudendi,  and  in  cups  and  blisters  to  the  thighs,  and  sina- 
pisms to  the  feet  and  legs.  In  all  cases,  the  state  of  the  patient’s  con- 
stitution will  furnish  indications  that  must  not  be  disregarded : thus, 
in  strong  women,  we  ought  chiefly  to  rely  upon  blood-letting ; in 
nervous  women,  we  should  combine  antispasmodics  with  the  mea- 
sures before  pointed  out;  and  in  patients  of  a feeble  constitution, 
where  the  pulse  is  not  frequent  nor  the  temperature  of  the  skin  much 
elevated,  recourse  might  be  had  to  stimulating  and  tonic  infusions 
prepared  with  the  periwinkle,  the  soap- wort,  the  cane-root,  or  Vir- 
ginia snake-root  $ but  it  should  not  be  forgotten  that  the  suppression 
of  the  lochia  generally  tends  to  the  production  of  most  dangerous 
inflammatory  diseases. 

The  symptomatic  cessation,  or  diminution  of  the  lochial  discharge, 
that  constitutes  an  immediate  consequence  of  any  disease,  and  which 
is  justly  looked  upon  as  a very  unfortunate  circumstance,  ordinarily 


652 


LOCHIA. MILK-FEVER. 


requires  no  treatment  beyond  that  appropriate  to  the  disorder  of 
which  the  suppression  constitutes  a sign.  It  is  worthy  of  remark, 
however,  that  a suppression  of  the  lochia  is  much  more  frequently 
a symptomatic  than  a primary  disorder ; that  is  to  say,  it  is  much 
more  commonly  the  effect  than  the  cause  of  disorders  with  which  it 
happens  to  coincide. 

The  immoderate  lochial  discharge  which  may  serve  to  reduce  a 
woman  to  a state  of  great  debility  and  prostration,  and  which  may 
happen  at  any  stage  of  the  secretion,  requires  no  other  treatment 
than  one  applicable  to  a case  of  metrorrhagia  or  leucorrhcea,  accord- 
ingly as  the  discharge  may  be  sanguineous,  serous  or  puriform.  A 
discharge,  of  a serous  nature,  ought  to  be  respected,  whenever  it 
coincides  with  a rapid  diminution  of  a dropsical  collection  affecting 
the  patient  during  her  pregnancy,  for  it  is  then  the  route  which 
nature  employs  to  evacuate  the  superabundant  serosity  that  consti- 
tuted the  ascites  or  anasarca. 

Changes  in  the  colour  of  the  lochia,  in  their  odour  and  consist- 
ence, as  they  are  mostly  the  results  of  some  malady  that  ought  to 
command- the  attention  of  the  practitioner,  do  not  constitute  a very 
important  symptom.  In  some  cases,  however,  the  lochia,  when 
already  puriform,  assume  a blackish  tint,  and  acquire  a fetid  odour, 
without  producing  any  apparent  consequence  as  to  the  health  of  the 
functions.  These  changes,  which  are  referable  to  the  decomposition 
of  some  clot,  or  a portion  of  the  placenta  that  may  have  been  left  in 
the  womb,  require  nothing  beyond  the  use  of  emollient  and  cleansing 
injections  into  the  vagina. 


OF  MILK-FEVER. 

Milk-fever  is  not  so  much  a real  disease  as  a febrile  movement 
requisite  to  determine  the  secretion  of  the  milk,  in  a woman  recently 
brought  to  bed. 

The  development  of  this  fever  is  announced  by  shooting  pain  and 
aching  in  the  breasts,  which  become  swollen  ; a swelling  that  is  often 
found  to  extend  as  far  as  the  axillary  glands,  so  that  there  are  some 
women  who,  when  thus  affected,  are  unable  to  bring  their  arms 
together,  but  are  obliged  to  keep  them  far  apart.  Yet  it  is  true  that 
there  are  cases  in  which  the  milk-fever  comes  on  without  any  tension 
of  the  breasts,  and  almost  without  any  febrile  action. 

The  symptoms  that  characterize  the  formation  of  the  milk-secre- 
tion are  generally  to  be  observed  about  the  third  day  after  the  birth 
of  the  child : in  certain  cases,  as  early  as  the  first  day,  or  the  second, 
and  even  as  late  as  the  sixth.  The  pulse  then  becomes  full  and  fre- 
quent ; the  temperature  rises,  the  skin  becomes  dry,  the  face  is 
flushed,  the  breasts  swell  and  become  painful,  the  thirst  increases, 
the  tongue  is  covered  with  a whitish  fur,  the  urine  is  more  scanty, 
and  higher-coloured  than  usual ; and  all  these  appearances  are  pre- 
ceded or  attended  by  a state  of  general  agitation  and  a headache 
without  rigors.  The  febrile  condition  increases  by  degrees,  and 


MILK-FEVER. 


653 


goes  off,  in  most  instances,  in  about  twenty-four  hours,  and,  in  some 
instances,  in  the  course  of  six,  eight,  or  twelve  hours. 

While  the  milk-fever  lasts,  the  lochial  evacuation  diminishes,  or  is 
temporarily  suspended;  but  a diminution  or  a suppression  of  the 
flow  ought  not  to  excite  any  solicitude,  for  they  are  occasioned  by 
the  febrile  action  that  brings  about  the  milk  secretion.  In  most  cases, 
calm  is  restored  after  the  flowing  of  an  abundant  perspiration,  and 
the  lochia  then  become  as  free  as  they  were  previously  to  the  attack. 

Women  who  nurse  their  children  have  little  or  no  milk-fever,  espe- 
cially when  they  take  care  to  let  the  child  suck  very  soon  after  its 
birth.  The  same  may  be  correctly  stated  of  those  women  who  per^ 
spire  very  copiously,  who  are  ordinarily  free  from  the  attack  of  this 
form  of  fever,  or,  at  least,  who  generally  have  it  very  slightly. 

The  treatment  of  a milk-fever  ought,*  in  some  sense,  to  be  purely 
hygienic.  When  the  secretion  of  milk  is  very  considerable,  and  the 
woman  does  not  give  suck,  she  ought  to  be  subjected  to  a severe 
diet,  to  take  demulcent  and  slightly  diaphoretic  drinks,  such  as  infu- 
sion of  mallows  and  linden,  of  violets  and  orange  flowers,  with  gum- 
arabic.  Should  the  fever  prove  to  be  too  violent,  it  might  be 
moderated  by  a small  bleeding  at  the  arm,  yet,  in  general,  it  requires 
merely  the  care  above  indicated. 

In  cases  where  the  breasts  are  too  much  swollen  and  painful, 
attempts  should  be  made  to  empty  them  by  allowing  the  infant  to 
draw  them,  and  where  the  woman  does  not  nurse,  by  rubbing  them 
gently  with  warm  olive-oil,  and  covering  them  with  fine  tow,  or  a 
lawn  handkerchief,  kept  on  with  a soft  napkin.  Care  ought  to  be 
taken  to  change  the  dressing  as  soon  as  it  becomes  moistened.  The 
flow  of  the  lochia  ought,  at  the  same  time,  to  be  promoted  by  means 
of  fumigations  to  the  vagina,  or,  what  is  still  preferable,  with  emol- 
lient narcotic  injections,  prepared  with  mallows  and  poppy-heads. 
These  measures  ought  to  be  put  in  force,  especially  where  the  lochia 
is  suspended,  either  before  or  subsequently  to  the  coming  of  the  milk. 

After  the  milk-fever,  the  tongue  is  white,  yellow  or  greenish,  the 
mouth  bitter  and  clammy.  Should  there  be,  likewise,  a loss  of  appe- 
tite, the  medical  adviser  might  advantageously  order  a mild  purgative 
dose,  such  as  manna,  castor  oil,  Seidlitz  water,  sulphate  or  phosphate 
of  soda,  and  even  the  sulphate  of  potash,  which,  whether  well  or 
ill  founded,  enjoys  a very  long-standing  reputation  as  an  antilactic 
article.  In  cases  where  the  tongue  is  red  and  lanceolate,  with  indu- 
bitable signs  of  a gastro-enteritis,  the  action  of  these  purgatives  will 
always  be  noxious,  and  they  should  be  therefore  proscribed.  In  like 
manner,  they  are  not  of  any  value  where  the  strength  and  appetite 
return  rapidiy  and  manifestly. 

The  other  kinds  of  supposed  antilactic  articles,  such  as  the  peri- 
winkle, which  quickens  the  pulse  and  weakens  the  stomach,  ought 
to  be  forbidden;  nevertheless,  we  might  allow  the  patient  to  take  a 
tisan  of  the  arundo  donax,  provided  she  have  some  confidence  in  its 
powers,  for  its  action  is  nearly  insignificant  and  inoffensive. 


654 


PUERPERAL  FEVER. 


OF  PUERPERAL  PERITONITIS. 

This  inflammation  of  the  peritoneum  differs  from  other  kinds  of 
peritonitis  only  in  the  circumstance  of  its  following  the  delivery  of 
the  woman. 

Notwithstanding  this  malady  must  have  existed  in  all  ages  of  the 
world,  it  seems  to  have  been  wholly  unknown  until  the  time  of  Hip- 
pocrates. That  illustrious  observer,  in  the  second  book  of  his  trea- 
tise on  the  diseases  of  women,  has  presented  us  with  a pretty  good 
description  of  it,  which  proves  that  the  principal  characteristics  of  the 
malady  had  not  escaped  his  notice,  but  that  he  regarded  it  as  an 
acute  affection  of  the  uterus,  brought  on  by  the  suppression  of  the 
lochia,  or  by  a laborious  labour.  This  opinion  of  the  Coan  sage 
was  reproduced  by  Galen,  Celsus,  Aetius,  Aretseus,  Pouteau,  Bos- 
quillon,  and  Lamothe. 

Chaussier,  Messrs.  Cayol.  Chomel,  Velpeau,  and  many  other 
writers  justly  suppose  that  puerperal  peritonitis  is  very  often  a con- 
secutive of  metritis.  Weikard  and  Horn,  agreeably  to  the  doc- 
trines of  Brown,  look  upon  the  disorder  which,  by  Strother  and 
Willis,  was  described  under  the  vague  title  of  puerperal  fever,  as 
being  in  its  nature  essentially  asthenic.  Vigaroux,  Etmuller,  Puzos, 
Levret,  and  especially  Doublet,  having  noticed  that  the  lochia  were 
not  suppressed  in  all  cases,  while,  according  to  their  view,  the  milk 
secretion  is  invariably  arrested,  came  to  the  conclusion  that  a perito- 
nitis is  merely  a metastasis  of  milk  to  the  abdominal  cavity.  Mi- 
chaelis  endeavours  to  prove,  in  his  memoir,  published  about  the 
beginning  of  the  present  century,  that  both  the  cause  and  the  gravity 
of  the  disease  depend  solely,  in  recently-delivered  women,  upon  the 
accumulation  of  the  lactic  principle  in  the  mass  of  the  blood. 

There  is  no  doubt,  at  present,  that  nearly  all  the  cases  designated 
by  authors,  under  the  appellations  of  puerperal  fever,  inflammation 
of'  the  bowels,  metastasis  of  the  lochia,  or  metastasis  of  milk  to  the 
abdominal  cavity,  were  real  cases  of  puerperal  peritonitis,  a denomi- 
nation under  which  modern  physicians  designate  an  inflammation  of 
the  peritoneum  coming  on  after  parturition. 

A very  great  number  of  recorded  cases  go  to  prove,  that  although 
this  disorder  is  often  simple,  yet  in  many  instances  it  is  complicated 
with  metritis  or  with  uterine  phlebitis ; that  is  to  say,  the  peritoneal 
inflammation  is  a secondary  occurrence,  and  takes  place  only  by 
contiguity  or  continuity.  We  shall,  hereafter,  point  out  the  means 
of  distinguishing  a simple  peritonitis  from  an  attack  of  metro- 
peritonitis. 

The  causes  of  peritonitis  ought  to  be  divided  into  predisponent  and 
occasional  causes;  among  the  former  ought  to  be  classed  the  state  of 
pregnancy,  errors  in  diet,  a sedentary  life,  domestic  anxiety,  too 
exciting  a diet,  or  diet  of  a bad  quality;  prolonged  inhabitation  of  a 
dark,  damp,  cold  house,  where  the  air  does  not  circulate  well;  the 
abuses  of  coitus;  lastly,  a plethoric  temperament,  a very  great  mo- 
bility of  the  vascular  system;  a delicate  constitution,  which  has  been 
weakened  and  rendered  easily  liable  to  become  disordered,  are  also 


PUERPERAL  FEVER. 


655 


looked  upon  as  predisponent  causes  of  the  disease  at  present  under 
consideration. 

Among  the  determining  causes  we  must  place  the  energetic  contrac- 
tions of  the  muscles  of  the  abdomen,  concurring  in  the  power  to  expel 
the  foetus,  the  action  of  cold,  the  influence  of  a tampon  made  use  of 
in  arresting  haemorrhage  after  delivery;  a long  and  difficult  labour; 
an  extreme  degree  of  confidence  inspired  by  a happy  delivery ; the 
remaining  of  the  lochia  within  the  womb  for  too  long  a period ; too 
much  company  and  conversation  soon  after  delivery  ; imprudence  in 
rising  too  soon  from  bed  after  the  birth  of  the  child,  and  engaging  in 
any  exercise  too  soon,  and  before  the  womb  can  have  resumed  its 
ordinary  position  and  recovered  its  non-gravid  volume ; moral  im- 
pressions of  too  severe  a character,  which  are  the  more  dangerous 
on  account  of  the  augmented  impressibility  of  the  newly-delivered 
woman;  the  too  sudden  suppression  of  some  usual  evacuation,  as  the 
insensible  perspiration,  the  lochia  or  the  milk ; cold  applied  to  the 
whole  body,  and  chiefly  to  the  breasts,  the  vulva,  and  the  abdominal 
muscles.  It  should  be  added,  that  the  impression  of  cold  and  damp 
is  one  of  the  most  frequent  causes,  and  that,  according  to  the  cases 
published  by  Delaroche,  more  women  die  in  child-bed  in  winter 
than  in  the  warm  seasons.  Savary  assures  us,  that  puerperal  peri- 
tonitis is  a very  rare  disease  in  Egypt;  and  Dr.  Solly  says,  that  he 
saw  no  case  of  it  in  South  America,  where  he  resided  for  about 
three  years. 

Puerperal  fever  sometimes  becomes  epidemic  in  hospitals  devoted 
to  lying-in  women.  Although  the  causes  that  give  rise  to  it  are  per- 
haps unknown,  they  appear  to  be  absolutely  local,  and  to  be  con- 
nected with  the  influence  of  a vitiated  atmosphere,  for,  in  general, 
such  epidemics  do  not  extend  among  females  in  the  same  city,  nor 
among  women  inhabiting  private  houses,  or  among  such  as  are  in 
other  hospitals.  Several  epidemics  of  this  sort  have  occurred  at 
Paris,  at  the  Hotel  Dieu,  at  the  Maison  d’Accouchements,  and  also 
at  the  Hopital  de  PEcole.  Broussais  says,  he  met  with  an  endemic 
peritonitis  in  certain  parts  of  Holland  and  Belgium. 

[The  history  of  the  epidemic  at  Aberdeen,  by  Gordon,  and  that  at  Leeds, 
by  Hey,  as  well  as  the  Sunderland  epidemic,  described  by  Dr.  Armstrong, 
are  very  conclusive  as  to  the  power  of  the  malady  over  patients  in  private 
houses.  It  is  well  known,  also,  that  puerperal  fever  has  been  epidemic  in 
various  parts  of  the  United  States  for  the  last  three  or  four  years. — M.] 

The  symptoms  of  puerperal  peritonitis  are  pretty  much  the  same 
as  those  of  other  forms  of  the  malady,  for  they  only  differ  as  to  the 
suppression  of  the  milk  and  the  lochia;  although  this  pathognomonic 
symptom  is  not  invariably  present,  and  may,  indeed,  occur  in  other 
maladies  coming  on  not  long  after  delivery.  Indeed,  the  lochia  may 
continue  to  flow  in  abundance,  and  we,  as  well  as  White,  Leake, 
Chaussier,  Dubois,  Deneux  and  others,  have  seen  the  breasts  con- 
tinue swollen  and  full  of  milk  up  to  the  last  moments  of  existence. 

The  invasion  of  puerperal  peritonitis  generally  takes  place  from 


656 


PUERPERAL  FEVER. 


the  second  to  the  5th  day  after  the  accouchement ; it  may,  however, 
come  on  at  a much  later  period,  as  the  tenth,  fifteenth  or  twentieth 
day.  Pinel  speaks  of  a nurse,  who  was  seized  with  it  at  the  end  of 
her  thirteenth  month.  It  may  also  happen,  that  the  disorder  comes 
on  immediately  after  the  termination  of  the  labour;  we  saw  a patient 
who  gave  birth  to  twin  children,  in  whom  the  attack  of  the  malady 
was  made  several  hours  previously  to  the  commencement  of  labour. 
Be  these  circumstances  as  they  may,  an  assault  of  puerperal  fever  is 
announced  by  a general  sense  of  lassitude,  uneasiness  and  weak- 
ness; by  headache,  vague  horripilation,  intermittent  chills,  attended 
with  tremors  and  numbness  of  the  limbs,  and  followed  by  that 
burning  and  internal  heat,  which  is  almost  always  felt  in  inflamma- 
tion of  the  serous  membranes.  These  signs  are  soon  followed  by 
pains  in  the  abdomen,  that  are  more  or  less  sharp,  and  that  are  felt 
at  various  points  in  the  belly,  which  will  not  tolerate  the  least  pres- 
sure ; the  patient  compares  her  pain  to  a feeling  of  twisting,  burning 
and  laceration,  which  is  increased  by  motion,  coughing,  hiccough, 
sneezing,  and  especially  by  the  action  of  vomiting,  and  any  motion 
that  disturbs  the  relations  of  the  peritoneum.  The  patient  lies  on 
the  back,  and  likes  to  have  the  head  weil  raised  on  pillows,  and 
instinctively  seeks  to  have  the  knees  drawn  up  so  as  to  relax  all  the 
muscles.  All  these  pains  are  attended  with  ardent  heat,  excessive 
thirst,  cephalalgia,  and  piercing  and  broken  cries;  the  respiration  is 
short,  laborious,  plaintive,  costal,  incomplete  ; hiccough  is  inevitable, 
provided  the  portion  of  peritoneum  that  invests  the  diaphragm  is 
affected  with  inflammation ; the  skin  is  sometimes  moist,  but  more 
generally  it  is  dry ; all  these  symptoms  coincide  with  diarrhoea,  or 
constipation,  with  vomiting,  with  meteorismus,  tumefaction,  and  ten- 
sion, greater  or  less,  of  the  belly,  and  frequently  with  a contraction 
of  the  anus.  The  countenance,  which  is  altered,  pale,  and  down- 
cast, becomes  covered  with  a cold  sweat,  and  always  bears  the  im- 
press of  suffering.  All  the  features  seem  to  be  drawn  upwards,  and 
towards  the  median  line,  and  give  the  true  type  of  the  facies  desig- 
nated under  the  title,  [face  grippe,)  contracted  countenance.  The 
lochia  becomes  suppressed  or  diminish  in  quantity,  and  the  flaccid  and 
occasionally  painful  mammae  contain  either  no  milk  or  but  a very 
small  quantity  of  it;  the  pulse  is  small,  contracted,  frequent,  concen- 
trated, and  often  irregular  and  intermittent ; however,  in  some  rare 
cases,  the  circulation  is  almost  undisturbed,  and  becomes  accelerated 
only  on  the  approach  of  dissolution.  The  urine  is  red,  turbid, 
scanty,  and  comes  off  with  smarting  pain.  The  pituitary  membrane 
is  dry  and  blackish;  the  tongue,  after  becoming  fuliginous,  pointed, 
tremulous  and  fissured,  loses  its  normal  characters  of  form  and  colour. 
The  mental  faculties  frequently  remain  sound  until  the  death  of  the 
patient;  but  in  almost  all  the  patients  we  observe  a feeling  of  con- 
sternation, discouragement  and  moroseness,  and  sometimes  delirium, 
extreme  agitation,  convulsions  and  subsultus  of  the  tendons.  In 
fine,  the  eye,  whose  mucous  membrane  is  often  observed  to  be  dry 
and  brownish,  with  the  pupil  gradually  dilating,  does,  in  some  cases, 
exhibit  the  appearance  of  death,  and  remains  motionless,  and  some- 


PUERPERAL  FEVER. 


657 


times  upturned.  Should  all  the  symptoms  here  enumerated,  when 
taken  separately,  not  characterize  a case  of  peritonitis,  the  physician 
should  found  his  judgment  only  upon  the  whole  of  them  together; 
and  he  should  never  forget  this  precept  of  the  father  of  medicine, 
“ Non  ex  uno  signo,sed  ex  concursu  omnium 

In  the  progress  and  termination  of  puerperal  peritonitis  there  is 
great  variety.  Yet  it  mostly  runs  through  its  periods  with  rapidity, 
and  in  some  instances  is  so  intense,  as  to  carry  off  the  victim  in  two 
or  three  days.  It  is  true,  however,  that  in  some  cases  it  is  protracted 
through  a period  of  from,  five  to  ten  or  even  twelve  days,  and  has 
even  been  known  to  last  beyond  the  fourteenth  day. 

The  disease  may  terminate  in  resolution,  suppuration,  or  gangrene, 
or  it  may  pass  into  a chronic  state,  [he  ought  to  have  added  the  termi- 
nation by  adhesion.  — M.]  The  termination  by  resolution,  which  is 
the  rarest,  the  most  favourable,  and,  consequently,  the  most  desirable, 
is  announced  about  the  fourth  day  or  up  to  the  sixth,  by  diminution  of 
the  pains  and  other  symptoms,  by  softness,  slowness  and  fulness  of  the 
pulse,  by  re-establishment  of  the  lochia,  and  of  the  secretion  of  milk, 

. and  by  the  ability  of  the  patient  to  lie  with  ease  either  on  the  back 
or  side. 

The  termination  by  suppuration,  which  is  one  of  the  most  com- 
mon, and,  unfortunately,  too  often  disastrous  results  of  the  disease, 
occurs  where  the  pain  and  tension  of  the  belly  become  less,  where 
the  pulse,  though  still  frequent,  becomes  soft ; where  the  patient  has 
slight  irregular  chills,  with  coldness  of  the  extremities ; and,  lastly, 
where  there  comes  on  a feeling  of  weight  in  the  hypogaster.  No 
doubt  as  to  the  existence  of  fluid  remains,  when  it  escapes  through 
some  opening,  or  when  its  fluctuation  becomes  evident  through  the 
parietes  of  the  abdomen. 

The  termination  in  gangrene,  which  is  the  rarest,  and  which  in- 
volves the  inevitable  death  of  the  patient,  may  be  suspected  where 
the  sensation  becomes  dull,  where  the  pains  cease  suddenly,  where 
the  abdomen  becomes  smaller,  though  the  discharges  be  not  rein- 
stated, and  lastly,  where  a sense  of  coldness  takes  the  place  of  the 
burning  heat,  while  the  pulse  at  the  same  time  grows  weak  and  inter- 
mittent, and  the  features  become  more  decidedly  altered.  Attacks  of 
vomiting  come  on,  attended  with  delirium ; the  sphincters  relax,  and 
admit  of  the  escape  of  insufferably  fetid  matter,  accompanied  by  a 
treacherous  calm,  in  the  midst  of  which  the  patient  expires. 

Where  an  attack  of  peritonitis  does  not  increase  in  violence,  but 
yet  continues  to  prevail,  it  passes  into  a chronical  form.  This  is  a 
sort  of  imperfect  termination,  which  may  be  known  by  the  following 
signs : the  abdomen  continues  painful  to  the  touch,  and  somewhat 
tumid,  or  else  it  becomes  more  and  more  tympanitic.  Sometimes 
there  are  intervals  of  calm,  which  lead  to  the  supposition  that  the 
cure  is  at  hand;  but  the  pain,  nausea  and  vomiting  recur  from  time 
to  time  ; the  loss  of  flesh,  and  emaciation,  become  extreme  ; at  length 
a colliquative  diarrhoea  comes  on,  attended  with  a low  continued 
fever,  with  consumption  and  marasmus ; the  effusion  goes  on,  and 
42 


658 


PUERPERAL  FEVER. 


the  patient  becomes  gradually  extinct.  In  fine,  cases  are  to  be 
observed  where  dropsy,  which  often  becomes  general  dropsy,  is  de- 
veloped, and  sometimes,  towards  the  close,  the  disease  becomes  exas- 
perated, and  again  assumes  the  acute  character. 

We  ought  to  observe,  likewise,  that  a chronic  peritonitis  may 
manifest  itself  upon  a lying-in,  without  being  preceded  by  any  acute 
symptoms;  in  such  a case,  it  is  evolved  slowly  and  insensibly;  the 
abdomen  is  painful  only  upon  pressure,  or  when  startled  by  some 
considerable  shock.  However,  there  are  cases  where  the  patient 
suffers  fixed  pain,  attended  with  heat,  elevation  of  the  pulse,  which 
is  accelerated,  especially  towards  evening.  In  fine,  she  has  dyspnoea 
and  cough,  particularly  when  lying  down.  Under  such  circum- 
stances, there  is  reason  to  suspect  that  effusion  is  taking  place  in  the 
abdomen. 

The  diagnosis  of  puerperal  fever  is,  beyond  contradiction,  the  most 
important  item  in  its  history.  The  disease  may  be  distinguished 
from  metritis,  in  respect  that  in  the  latter  the  pain  is  dull,  gravative, 
and  confined  to  a small  space  in  the  hypogastrium.  Where  this  is 
the  case  at  first,  yet  the  pain  afterwards  extends  over  the  whole  sur- 
face of  the  abdomen,  the  metritis  is  complicated  with  peritonitis;  the 
interior  of  the  vagina  communicates  to  the  finger,  as  it  does  in  metri- 
tis, the  sensation  of  an  acrid  and  burning  heat ; the  os  tineas  is  swol- 
len, tense  and  very  sensitive.  A case  of  peritonitis  may,  likewise,  be 
distinguished  from  one  of  uterine  phlebitis,  which  often  complicates 
it,  by  the  acuteness  of  the  pains,  and  by  their  extending  to  all  parts 
of  the  abdominal  cavity.  (Edema  of  the  lower  limbs,  and  especially 
a considerable  development  of  the  external  and  superficial  veins  of 
the  abdomen,  are  signs  that  best  characterize  the  case  of  uterine 
phlebitis. 

The  prognosis  of  puerperal  peritonitis  generally  leaves  little  to 
hope  for;  yet,  notwithstanding  the  dangers  to  which  it  exposes  the 
patient,  it  may  be  considered  as  favourable,  where  the  volume  of  the 
belly  grows  less  and  less,  where  the  lochial  discharge  returns,  where 
the  secretion  of  the  milk  is  restored,  and,  lastly,  where  some  of  the 
symptoms  are  absent,  where  the  pain  becomes  less  acute,  where  it  is 
felt  over  a smaller  extent  of  surface,  and  where  the  pulse  loses  its 
frequency.  In  general,  the  disease  is  the  more  dangerous  as  the 
inflammation  is  more  extensive,  and  as  the  period  of  its  development 
approximates  to  the  moment  of  labour.  It  is  always  mortal  when  it 
commences  before  the  pains  of  parturition,  and,  particularly,  when 
the  female  has  a twin  pregnancy.  The  prognosis  again  is  generally 
favourable,  if  the  affection  present  no  remarkable  sympathetic  phe- 
nomenon, for  a prompt  and  energetic  treatment  usually  arrests  its  pro- 
gress. In  any  case,  it  is  difficult  to  make  a positive  prognosis  before 
the  fifth,  eighth  or  tenth  day  of  the  disease,  since  before  that  period 
we  cannot  ascertain  its  probable  course  or  duration.  As  to  the  prog- 
nosis of  chronic  peritonitis,  it  is  always  unfavourable,  in  consequence 
of  the  disorganizations  which  it  occasions ; nevertheless,  cases  have 
been  observed  which  prove  that  it  may  be  cured;  but  then  its  true 
character  has  been  recognized  early,  and  moreover,  it  is  of  a simple 


PUERrERAL  FEVER. 


659 


form,  without  complication,  and  without  considerable  effusion  ; and 
if  fever  exists,  it  is  accompanied  by  hectic  phenomena. 

The  anatomical  characters  of  puerperal  peritonitis  are  the  follow- 
ing : if  the  female  have  died  from  a very. acute  attack,  one  severe 
enough  to  destroy  life  in  thirty-six  or  forty- eight  hours,  which  is  rare, 
the  serous  membrane  often  presents  no  trace  of  alteration,  either  in 
its  colour  or  organization.  The  peritoneum  may  even  seem  to  be 
entirely  healthy,  or  to  be  merely  slightly  dry  and  red ; but  when 
death  has  been  less  sudden  and  prompt,  that  is  to  say,  when  it  has 
not  occurred  until  the  third  or  fifth  day,  the  intestines  are  retracted 
upon  themselves ; the  vessels  which  ramify  upon  the  peritoneum  are 
red  and  congested,  particularly  at  the  points  where  the  inflammation 
has  been  most  active.  Non-organized  false  membranes  and  small  ab- 
scesses and  collections  of  serum  are  sometimes  met  with  in  the  uterus, 
broad  ligaments,  Fallopian  tubes  and  ovaries.  Often,  also,  the  cellu- 
lar layer  which  unites  the  peritoneum  to  the  abdominal  walls  and 
viscera  is  distended  by  a gelatinous  fluid  and  by  a limpid,  thick,  or 
reddish  and  more  or  less  abundant  serosity,  in  such  a way  as  com- 
pletely to  isolate  the  serous  membrane.  Lastly,  in  some  cases,  arc 
found  lactiform  collections,  in  which  float  whitish  flocculi,  resembling 
whey  that  has  not  been  strained.  It  was  the  colour  and  milky 
appearance  of  this  fluid,  indeed,  which  caused  Willis,  Puzos,  Levret, 
Doublet,  and  some  others,  to  fall  into  the  error  of  regarding  these 
collections  as  the  result  of  a deviation  and  metastasis  of  milk  into  the 
peritoneal  cavity.  They  supposed  that  the  lactescent  urine  and 
whitish  matters  which  some  women,  affected  with  peritonitis,  pass 
by  stool,  must  have  come  from  the  same  source. 

In  chronic  peritonitis,  the  congested  membrane  is  thickened  and  dot- 
ted over  with  whitish  granulations;  the  intestines  are  glued  together, 
as  it  were,  and  united  so  as  to  form  a mass,  and,  between  the  folds 
of  the  peritoneum  is  found  a yellowish,  muddy,  purulent  and  green- 
ish fluid,  holding  fragments  of  false  membrane  in  suspension.  Lastly, 
in  some  cases  the  peritoneum  has  a lardaceous  and  cancerous  appear- 
ance, and  the  inter-peritoneal  tissue  of  the  epiploon  is  often  the  seat 
of  ulcerations  more  or  less  numerous. 

The  prophylactic  treatment  of  peritonitis  consists  in  removing 
recently-delivered  women  from  the  influence  of  the  causes  which 
produce  it.  Those,  for  example,  who  are  deprived  of  the  happiness 
of  nursing  their  own  children,  ought  to  be  subjected  to  a rigid  diet ; 
they  should  avoid,  as  much  as  possible,  the  visits  of  friends,  cold, 
excessive  heat,  noise,  odours,  and  we  should  endeavour  to  prevent 
the  vivid  emotions  of  the  soul,  which  make  an  impression  the  more 
unfavourable  to  women  in  childbed,  because  their  nervous  mobility 
is  at  that  time  greatly  augmented.  Lastly,  the  disease  may  often  be 
prevented  by  advising  women  to  suckle  the  child. 

The  curative  treatment  of  this  acute  disease  ought  to  be  the  more 
prompt,  energetic  and  skilfully  conducted,  because  its  symptoms  are 
formidable,  its.  progress  rapid,  and  its  clanger  always  great.  The 
treatment  ought,  therefore,  to  be  essentially  antiphlogistic,  and  to 
consist,  first,  of  a large  bleeding,  to  be  repeated  more  or  less  fre- 


660 


PUERPERAL  FEVER. 


quently,  according  to  the  intensity  of  the  inflammation,  the  hardness 
of  the  pulse,  the  pathological  sympathies  which  occur,  and  the 
strength  of  the  patient.  This  first  indication  fulfilled,  there  should 
be  applied  to  the  abdomen,  at  one,  two,  or  three  different  times,  from 
forty  to  one  hundred  and  fifty  leeches,  according  to  the  constitution 
of  the  patient  and  the  violence  of  the  disease.  Leeches  to  the  vulva 
are  likewise  very  useful  in  relieving  the  engorgement  of  the  uterus 
and  recalling  the  lochia ; but  it  is  necessary,  in  all  cases,  to  precede 
their  application  by  one  or  two  large  bleedings  at  the  arm.  It  is  by 
the  energetic  employment  of  these  means  especially,  that  we  must 
endeavour  to  regulate  the  disease  at  its  very  beginning,  because,  in 
a few  days,  sanguine  emissions  are  no  longer  so  efficacious,  and  when 
there  is  complete  prostration  of  the  strength,  may  even  augment 
this  condition  and  render  the  death  of  the  patient  more  rapid.  We 
must  resort,  at  the  same  time,  to  emollient  and  narcotic  fomentations, 
to  mucilaginous,  acidulated  and  tepid  drinks,  and,  lastly,  to  the  most 
rigorous  diet.  The  iced  applications  and  aspersions,  and  the  cold 
baths  recommended  by  Van  Swieten  and  Broussais,  seem  to  us  to 
be  dangerous,  and  likely  to  produce  'gangrene.  Warm  baths  are 
rarely  endowed  with  the  utility  attributed  to  them,  and  their  action 
often  turns  against  the  patient.  In  fact,  the  weight  of  the  liquid,  the 
impression  of  the  cold,  the  painful  position  and  the  displacement 
which  they  require,  seem  to  us  motives  sufficient  for  their  rejection. 
Enemata  of  decoction  of  marsh-mallow,  of  flax-seed  or  of  poppy- 
heads,  may  assist  the  treatment ; but  they  ought  not  to  be  used  in  the 
first  days  of  the  disease,  as  they  increase  the  pain,  and  the  greatest  care 
should  be  taken,  in  administering  them,  not  to  disturb  the  patient,  and 
to  inject  only  a small  quantity  into  the  large  intestine  at  once;  that  is 
to  say,  to  use  only  a fourth,  or,  at  most,  half  of  the  usual  quantity. 

Should  the  patient  be  so  irritable  that  the  drinks,  even  when  taken 
in  very  small  quantity,  are  rejected  by  vomiting,  we  must,  in  order 
to  avoid,  as  much  as  possible,  the  violent  succussions  so  produced, 
allay  the  thirst  by  means  of  slices  of  orange,  or  by  a few  spoonfuls 
of  Seltzer  water.  It  is  well,  also,  to  promote,  as  much  as  possible, 
the  secretions  from  the  mucous  membranes,  by  means  of  warm  sudo- 
rific drinks ; and  we  should  endeavour,  in  particular,  to  excite  the 
action  of  the  skin  by  vapour-baths,  which  were  successfully  em- 
ployed by  Chaussier. 

The  injurious  effects  of  epispastics  applied  to  the  abdomen,  in  the 
acute  stage  of  peritonitis,  should  lead  us  to  avoid  their  use ; they 
should  be  employed  only  when  the  disease  has  become  chronic,  or  in 
the  second  stage  of  the  acute  form. 

To  remove  the  constipation,  we  may  resort  to  the  use  of  enemata 
of  oil,  or  to  mild  laxatives ; especially,  after  the  example  of  Chaus- 
sier, to  castor  oil,  mixed  with  equal  parts  of  syrup  of  succory  or 
rhubarb.  The  use  of  drastic  purgatives,  recommended  by  the  Eng- 
lish writers,  ought  to  be  proscribed  in  all  cases ; they,  however, 
employ,  with  advantage,  calomel  in  divided  doses. 

The  use  of  emetics,  principally  ipecacuanha  in  emetic  doses,  re- 
commended by  Doublet  and  Doulcet,  can  be  beneficial  ouly  during 


PUERPERAL  FEVER. 


661 


the  earliest  stages  of  the  disease ; given  later,  they  aggravate  the  symp- 
toms by  the  efforts  at  vomiting  which  they  occasion.  The  method 
of  the  above  physicians  consisted  in  giving,  at  the  appearance  of  the 
earliest  symptoms,  twelve  grains  of  ipecacuanha  in  two  doses,  and 
repeating  the  emetic  several  times,  according  to  the  obstinacy  of  the 
case.  We  ought  to  remark,  that  the  success  of  this  mode  of  treatment 
has  not  been  proved,  and  that  most  of  the  physicians  of  the  present 
day  have  renounced  it. 

We  have  still  to  speak  of  a most  valuable  therapeutical  agent,  to 
wit,  mercury,  employed  first  by  Armstrong,  Vandeusande,  and,  more 
recently,  by  Professor  Velpeau,  who  has  shown  all  the  advantages 
of  frictions  of  the  abdomen  with  mercurial  ointment  in  the  proportion 
of  from  one  to  two  drachms,  repeated  every  two  or  three  hours.* 
Eight  or  ten  grains  of  calomel,  daily,  may  be  given  at  the  same  time, 
while  continuing,  with  great  exactness,  the  mercurial  frictions,  up  to 
the  disappearance  of  the  morbid  symptoms,  which  generally  diminish 
when  the  salivation  begins  to  be  established. 

The  spirits  of  turpentine  also  has  been  recommended,  both  inter- 
nally and  in  the  form  of  enemata,  by  Douglas  Kinneir  and  Mayer. 
It  may  be  prescribed  in  mixture,  prepared  in  the  following  manner: 

Take  Spirits  of  Turpentine,  an  ounce  and  a half;  Narbonne  honey,  two  drachms; 
water,  two  ounces.  One-third  to  be  taken  at  intervals  of  two  hours. 

When  peritonitis  terminates  by  resolution,  the  physician  has  merely 
to  watch  the  disease  and  encourage  the  favourable  actions  which 
may  tend  to  make  their  appearance.  In  the  termination  by  suppu- 
ration, the  patient  is  destined  to  certain  death,  unless,  what  is  unfor- 
tunately very  rare,  the  pus  escapes  externally.  Therefore,  as  soon 
as  fluctuation  becomes  evident,  we  should  endeavour  to  imitate 
nature,  by  performing  the  operation  of  paracentesis.  Again,  when 
the  disease  passes  into  the  chronic  form,  the  employment  of  leeches, 
of  rubefacients,  of  dry  frictions  to  the  skin,  of  vesicatories  to  the 
thighs  and  abdomen,  of  mercurial  frictions,  and  of  baths  of  different 
kinds,  may  assist  in  the  treatment,  and  bring  about  a cure,  which. is 
rare,  but  not  always  above  the  resources  of  the  art.  When  the 
serous  effusion  becomes  considerable,  diuretics  ought  to  be  prescribed, 
and  tapping  should  be  performed  at  an  early  period,  if  the  fluid  is 
not  absorbed.  It  is  well  to  add  that,  in  cases  of  acute  peritonitis,  we 
may  assist  the  flow  of  milk  in  the  breasts  by  keeping  them  warm,  by 
covering  them  with  cups,  and  especially  by  frequent  drawing.  We 
might  also  endeavour  to  remove  the  meteorism,  by  means  of  a large 
gum-elastic  catheter,  kept  a longer  or  shorter  time  in  the  rectum,  so 
as  to  give  issue  to  the  gases  that  distend  the  intestines. 

OF  UTERINE  PHLEBITIS. 

Of  all  the  diseases  which  occur  after  labour,  uterine  phlebitis  is 
certainly  one  of  the  most  frequent  and  most  dangerous.  Obscure  in 
its  symptoms,  insidious  in  its  progress  and  complications,  it  was  mis- 


* Revue  Medicate,  January,  1S37. 


662 


UTERINE  PHLEBITIS. 


understood  by  the  ancients,  who,  being  destitute  of  the  aid  of  patho- 
logical anatomy,  could  have  only  uncertain  ideas  as  to  the  nature  of 
the  affection.  Though  partially  understood  by  Leake,  Chaussier, 
Schwilgai,  Clarke,  Wilson,  Meckel,  M.  Ribes,  and  Husson,  it  had 
nearly  been  forgotten  when  Dance,  and,  after  him,  M.  Tonnele, 
recalled  the  attention  of  physicians  to  it  by  publishing  several  cases, 
which  render  its  history  complete.  Since  then,  all  the  cases  have 
been  more  than  confirmed,  by  the  labours  of  MM.  Breschet,  Andral, 
Louis,  Cruveilhier,  Perreau,  Garget  of  Pampeluna,  and  some  others. 

Amongst  the  causes  of  uterine  phlebitis,  should  be  ranked  a long 
and  difficult  labour,  during  the  expulsion  of  the  foetus,  and  certain 
individual  predispositions;  long-continued  pressure  of  the  head  of  the 
child  against  the  neck  of  the  uterus ; cold  and  humid  temperature, 
especially  during  winter ; crowded  lying-in  wards ; lastly,  tractions 
exerted  upon  the  placenta,  immediately  after  delivery,  in  such  a way 
that  the  uterine  veins,  separated  too  suddenly  from  the  parts  with 
which  they  are  in  contact,  remain  patulous  and  in  direct  communica- 
tion with  an  inflamed  surface,  with  the  lochia,  or  with  clots  of  decom- 
posed blood,  and  sometimes  with  putrefied  and  softened  portions  of 
placenta.  In  all  these  cases,  the  uterine  veins  are  nearly  in  the  same 
circumstances  as  when  they  are  near  an  ill-conditioned  wound,  and 
consequently  in  a state  to  invite  inflammation. 

To  these  causes  of  uterine  phlebitis,  we  will  add  the  injection  of 
iced  and  astringent  fluids,  into  the  cavity  of  the  uterus,  to  arrest  a 
dangerous  hsemorrhage ; suppression  of  the  milk ; compression  of  the 
hypogastric  region ; indulgence  in  improper  diet ; premature  exer- 
cise ; the  excessive  susceptibility  of  recently-delivered  women ; and, 
lastly,  any  imprudence  committed  by  them,  after  delivery,  and  parti- 
cularly latent  inflammation  of  the  mucous  tissue,  or  of  the  proper 
tissue  of  the  gestative  organs. 

Progress  and  seat.  Inflammation  of  the  veins  of  the  uterus 
generally  commences  at  the  orifices  of  the  uterine  sinuses,  exposed 
by  the  separation  of  the  placenta,  as  an  amputation  exposes  the  veins 
of  one  of  the  limbs.  The  inflammation  soon  extends  to  the  veins, 
into  which  the  uterine  sinuses  empty,  which,  by  contiguity,  transmit 
the  inflammation  to  the  proper  tissue  of  the  uterus,  which  constitutes 
a parenchymatous  uterine  phlebitis,  complicated  with  metritis.  We 
ought  to  remark,  however,  that  the  last  affection  may  precede  the 
phlebitis,  and  that  this  may  extend  beyond  the  limits  of  the  walls  of 
the  uterus,  follow  the  direction  of  the  uterine  veins  furnished  by  the 
hypogastrics,  and  often  extend  along  the  ovarian  veins  to  the  inferior 
cava.  It  is  proper  to  add,  moreover,  that  the  phlebitis  may  exist 
upon  one  side  of  the  uterus  only,  and  that  it  is  generally  the  right 
side  which  is  affected,  probably  because  the  insertion  of  the  placenta 
takes  place  more  frequently  on  this  side  than  on  the  left. 

The  symptoms  of  uterine  phlebitis  vary  according  to  the  stage  of 
the  disease;  in  the  first  stage,  the  disease,  which  is  purely  local, 
ordinarily  manifests  itself  from  the  second  to  the  third  day  by  the  * 
symptoms  of  metritis,  that  is  to  say,  by  irregular  rigors,  by  constant 
feeling  of  weight  in  the  lumbar  region,  and  by  pain  confined  to  the 


UTERINE  PHLEBITIS. 


663 


hypogastrium  and  iliac  fossse,  often  on  one  side  only,  which  is  that  to 
which  the  insertion  of  the  placenta  upon  the  womb  corresponds.  To 
these  symptoms  must  be  added  sudden  suppression  of  the  lochia, 
shrinking  of  the  breasts,  smallness  and  frequency  of  the  pulse,  dry- 
ness of  the  skin,  redness  and  dryness  of  the  tongue,  engorgement  of 
the  uterine  tumour,  which  augments,  instead  of  diminishing,  as  the 
inflammation  advances ; lastly,  a discharge  of  puriform,  thick,  and 
generally  fetid  matters  from  the  vulva ; tumefaction  and  pain  of  the 
cervix  uteri,  and  sensibility  of  the  hypogastrium,  which  is  more  acute 
than  that  which  is  usually  present  after  delivery. 

The  second  stage,  which  is  that  in  which  suppuration  takes  place, 
is  marked  by  diminution  of  the  local  pain  and  by  the  development  in 
the  digestive  tube  of  gaseous  products;  lastly,  the  third  stage,  marked 
by  the  absorption  of  pus  into  the  torrent  of  the  circulation,  presents 
general  symptoms  of  a more  dangerous  character;  for  there  is  at 
that  time  excited  imagination,  and  generally  delirium;  the  skin  as- 
sumes an  earthy  hue;  the  eyes  are  sunken,  and  the  pupils  dilated; 
the  face  is  pinched  and  covered  with  a cold  sweat,  and,  moreover, 
there  occurs  a sort  of  insensibility,  which  renders  the  patient  uncon- 
scious of  pain ; sometimes  the  limbs  become  the  seat  of  sudden  swell- 
ing, of  evident  fluctuation  and  painful  induration,  bearing  all  the 
marks  of  a deeply-seated  abscess.  Later  in  the  disease,  all  the  symp- 
toms become  aggravated,  the  extremities  grow  cold,  the  pulse  more 
frequent  and  compressible,  and  to  these  various  symptoms  are  added 
loquacity,  a constant  sardonic  laugh,  picking  at  the  bed-clothes,  sin- 
gultus, fainting,  and  death,  which  terminates  the  scene. 

The  diagnosis  of  phlebitis  in  the  first  stage  differs  but  little  from 
that  of  metritis,  and  it  is  by  the  symptoms  which  denote  the  introduc- 
tion of  pus  into  the  circulation  alone,  that  the  existence  of  phlebitis 
can  be  demonstrated.  The  extension  of  the  disease  to  the  large 
venous  trunks  may  be  inferred,  when  oedema  of  the  lower  extremi- 
ties, and  a peculiar  pufliness  about  the  pelvis,  exist.  Again,  there  is 
a sign  of  considerable  value  in  the  diagnosis  of  phlebitis,  which  is  the 
development  of  the  external  and  superficial  veins  of  the  abdominal 
walls ; moreover,  venous  inflammation  is  distinguished  from  perito- 
nitis, by  the  acuteness  of  the  pains  in  the  latter  disease,  and  especially 
by  their  extension  to  the  whole  abdominal  cavity.  To  conclude,  in 
phlebitis  the  delirium  is  greater,  and  the  rigors  which  precede  suppu- 
ration in  the  uterine  veins  are  more  marked,  and  return  periodically, 
as  in  an  attack  of  pernicious  fever,  which  is  not  the  case  in  perito- 
nitis. 

The  prognosis  of  the  disease  under  consideration  is  as  uncertain 
as  its  duration;  nevertheless,  it  may  be  regarded  in  general  as  being 
very  unfavourable,  though  in  many  cases  we  might  arrest  its  pro- 
gress at  first  with  as  much  facility  as  in  ordinary  phlebitis.  But  the 
uncertainty  of  the  diagnosis  in  the  early  stage,  and  especially  the 
failure  of  the  patients  or  their  friends  to  ask  for  advice,  render  the 
prognosis  almost  always  unfavourable.  In  general,  when  the  inflam- 
mation is  confined  to  the  veins  of  the  uterine  walls,  we  may  hope  for 
much  from  the  resources  of  the  art  and  the  efforts  of  nature ; but 


f 64 


UTERINE  PHLEBITIS. 


when  it  extends  to  the  spermatic  veins,  purulent  absorption  and  its 
consequences  are  much  to  be  apprehended.  This  phlegmasia,  in  a 
word,  is  always  more  dangerous  than  simple  metritis.  It  usually 
terminates  during  or  towards  the  end  of  the  third  week ; but  it  may 
also  last  a much  longer  time,  and  prove  fatal  four  months  after  its 
commencement,  as  is  proved  by  the  tenth  case  reported  in  the  essay 
of  M . Dance. 

The  cadaveric  lesions  vary  according  to  the  duration  of  the 
disease.  When  it  has  lasted  but  a short  time,  the  point  of  inser- 
tion of  the  placenta  is  red  and  covered  with  a blackish  putrescent 
matter ; the  uterus  is  always  larger  than  it  ought  to  be  at  the  time 
which  has  elapsed  since  the  delivery,  and  the  uterine  veins  are  pustu- 
lous and  contain  more  or  less  pus.  If  the  phlebitis  has  existed  for 
some  time,  the  tissue  of  the  uterus  is  softened,  and  when  cut  into  and 
squeezed,  drops  of  pus  are  seen  to  exude  ; pus  is  often  found,  also, 
in  the  spermatic,  and  in  the  external  and  internal  iliac  veins,  and 
sometimes  the  cavity  of  the  abdomen  is  the  seat  of  a sero-purulent 
effusion,  and  the  muscular  interstices  of  the  superior  and  inferior  ex- 
tremities and  the  articulations  even,  likewise  present  extensive  puru- 
lent deposits.  Lastly,  the  brain  is  more  or  less  congested,  and  in 
some  cases  the  spleen,  liver  and  lungs  are  also  involved  in  the  suppu- 
ration. 

The  treatment  of  phlebitis  must  vary  according  as  the  disease  is 
in  the  first  period  of  the  symptoms  or  in  the  two  others,  to  wit,  in 
that  of  suppuration  or  of  the  passage  of  pus  into  the  torrent  of  the 
circulation. 

The  treatment  of  the  first  period  consists  in  the  use  of  general 
bleedings,  in  the  application  of  leeches  to  the  vulva,  to  the  inside 
of  the  thighs,  and  to  the  anus,  and  in  the  energetic  employment  of 
all  the  antiphlogistics,  such  as  frequently-repeated  emollient  injec- 
tions, baths,  poultices  sprinkled  with  laudanum  for  the  hypogastrium, 
rigorous  diet,  demulcent  and  sedative  drinks  and  mixtures,  and,  last- 
ly, the  withdrawal  of  all  causes  which  might  irritate  or  disturb  the 
patient. 

During  the  period  of  suppuration  even,  general  bleeding  is  some- 
times useful ; but  it  is  the  administration  of  tartar  emetic  and  ipeca- 
cuanha in  large  doses,  which  promises  the  best  chances  of  success. 
We  once  had  occasion  to  observe  the  good  effects  of  tartar  emetic, 
as  MM.  Nauche  and  Nouat  had  done  before  us.  To  these  means 
might  be  added  vaginal  injections  of  some  solution  charged  with 
chlorine,  and  if  symptoms  of  purulent  absorption  were  present,  it 
would,  perhaps,  be  proper  to  attempt  transfusion  of  the  same  liquid 
into  the  veins  in  the  neighbourhood  of  the  affected  part,  in  order  to 
endeavour  to  snatch  the  patient  from  certain  death.  We  might  like- 
wise resort  to  the  employment  of  powerful  revellents,  to  sinapisms, 
to  blisters  applied  to  the  thighs  and  legs,  or  to  sudorifics  and  all  the 
excitants  of  the  cutaneous  system,  especially  to  the  acetate  of  ammo- 
nia, in  the  dose  of  five  or  six  drops  in  a cup  of  tisan ; it  would  be 
proper  to  associate  with  these  means  remedies  having  a sedative 
action  upon  the  nervous  system,  as,  for  instance,  camphor,  assafoetida, 


PUERPERAL  PHLEBITIS. 


665 


cinchona  or  any  of  the  bitters ; lastly,  if  the  uterine  phlebitis  were 
complicated,  the  treatment  should  be  modified  according  to  the  nature 
of  the  complications.  It  is  well  to  add,  moreover,  that,  notwithstand- 
ing the  prostration  and  feebleness  of  the  pulse,  general  bleeding  may 
sometimes  prove  useful,  for  it  has  been  proved  by  experiments  upon 
animals,  that  sanguine  evacuations  were  one  of  the  best  means  to 
modify  the  evil  effects  of  the  introduction  of  putrid  matters  into  the 
circulation. 


OF  OTHER  KINDS  OF  PUERPERAL  PHLEBITIS. 

Phlebitis  occurring  after  delivery  has  also  been  observed  in  the 
hypogastric,  external  iliac,  and  primitive  iliac  veins,  in  the  crurctles 
and  in  the  inferior  cava.  The  disorder  may  be  known  by  the  swell- 
ing and  pain  discovered  along  the  track  of  the  inflamed  vein,  by  the 
swelling  of  the  adjacent  cellular  tela,  and  which  in  some  instances 
extends  over  the  whole  limb  ; and  likewise  by  a sensation  resembling 
that  produced  by  feeling  a sort  of  cord  running  in  the  direction  of  the 
vessel,  and  which  rolls  under  the  finger.  The  causes  of  the  different 
kinds  of  puerperal  phlebitis  are  the  same  as  those  that  give  rise  to 
uterine  phlebitis;  they  are  therefore  to  be  treated  by  like  measures, 
such  as  general  blood-letting,  the  application  of  leeches  to  the  hypo- 
gaster,  which  should  be  resorted  to  immediately  upon  the  appearance 
of  the  symptoms,  and  repeated  until  the  pain  ceases ; by  emollient 
cataplasms,  and  protracted  use  of  the  bath,  continued  as  long  as  three 
or  four  hours ; by  irrigations  into  the  womb,  by  means  of  a*  proper 
syringe,  and,  finally,  by  the  employment  of  gentle  purgatives. 

[1  have  deferred  until  the  present  occasion,  the  addition  of  any  note  upor 
the  subject  of  puerperal  fever,  and  perhaps  I might  have  spared  the  reader 
the  present  addition,  were  it  not  that  I feel  very  desirous  to  place  in  as  clear 
a light  as  possible  the  therapeutical  considerations  that  flow  out  of  the  view 
of  these  affections  which  regards  them  as  diseases  of  an  inflammatory  type. 

Among  the  numerous  individuals  who  have  made  public  their  opinions, 
and  the  experience  on  which  they  were  founded,  great  discrepancies  are 
found  to  exist.  One  party  pushing  the  use  of  the  most  vigorous  antiphlo- 
gistics  to  the  utmost;  another  recommending  their  very  cautious  use,  while 
others  seem  afraid  of  them,  except  under  the  most  guarded  limitations. 

So  far  as  I can  learn,  a discrepancy,  equally  as  great  as  that  among  foreign 
writers,  exists  in  the  profession  on  this  side  of  the  Atlantic.  The  question 
as  to  the  nature  and  treatment  of  childbed  fever  being  a most  important  one, 
we  believe  that  we  shall  confer  a benefit  upon  the  public  at  large,  and  upon 
our  brethren  in  particular,  by  calling  their  attention  anew  to  the  subject. 

So  rapid  and  fatal  in  their  course  have  been  the  epidemic  and  even  the 
sporadic  forms  of  puerperal  fever,  and  so  evident  and  early  have  been  the 
signs  of  great  prostration,  or  exhaustion  and  mortal  proclivity  of  the  vital 
powers,  that  we  have  no  room  for  surprise  at  the  tendency  of  mankind  to 
view  them  as  ataxic  or  typhous  in  their  very  nature ; and  so  requiring,  on 


666 


PUERPERAL  FEVER. 


that  account,  a careful  avoidance  of  strong  antiphlogistic  or  debilitating  mea- 
sures. The  idea  of  typhus  is  inseparably  connected,  in  many  minds,  with 
that  of  great  muscular  weakness,  tremors,  dry  tongue — with  stimulants  and 
cordials,  and  all  the  means  of  rapid  reparation.  In  such  persons  it  is  enough 
to  know  that  to-morrow  the  patient  will  be  weaker,  in  order  to  lead  them  to 
obviate  that  fearful  debility  to-day  by  opium  and  brandy,  and  an  alexipharmic 
course,  and  beef  tea,  &c.  <fcc.  Dr.  Win.  Hunter,  who  saved  but  one  case 
out  of  thirty-two,  persisted  to  the  last,  according  to  Dr.  Mackintosh,  in  be- 
ginning the  treatment  with  a generous  glass  of  brandy;  and  there  are  many 
gentlemen  who,  having  repeatedly  seen  the  belly  filled  with  the  fluid  depo- 
sits of  extensive  peritoneal  inflammations,  and  the  veins  gorged  with  pus, 
the  product  solely  of  inflammation,  still  contend  that  the  employment  of 
venesection  is  very  dangerous , and  requires  great  consideration  of  the  con- 
stitution and  habits  of  the  patient,  and  is  to  be  practised  only  on  the  most 
favourable  subjects.  Not  only  are  there  to  be  found  respectable  brethren 
holding  these  views,  but  even  of  those  who  preach  the  opposite  doctrines, 
there  are  many  who,  though  bold  in  recommending  the  lancet  to  others,  yet, 
in  their  own  practice,  stop  short  of  the  free  use  of  this  measure. 

The  mischievous  effects  of  error  are  continued  long  after  the  error  itself 
is  overthrown  : a man  who  has  been  trained,  by  bad  teaching,  to  look  upon 
a grave  disorder  as  of  a typhous  nature,  and  therefore  to  be  treated  by  stimu- 
lating means,  finds  it  very  difficult  to  liberate  himself  from  the  rules  of 
action  imposed  by  his  early  prejudices,  which  continue  to  bias  his  practice 
even  long  after  his  judgment  has  been  fully  enlightened. 

At  the  present  day,  we  know  that  women  in  childbed  are  liable  to  attacks 
of  chills  or  rigors,  followed  by  pain  in  the  region  of  the  womb,  with  a very 
frequent  pulse,  rising  speedily  to  120  or  150  beats  per  minute;  and  soon 
after  by  distension  of  the  abdomen,  pain,  and  other  symptoms,  which  mark 
the  childbed  fever.  This  fever  proves  fatal  to  many  of  the  patients  attacked 
with  it;  and  the  examinations  of  the  bodies  of  those  who  die  reveal  either 
extensive  inflammation  of  the  peritoneum  alone,  or  of  the  womb  alone, — or 
of  the  womb  and  peritoneum  both.  In  some  of  the  cases  the  womb  is 
proved  to  have  become  gangrenous  or  softened  by  inflammation ; and  in 
others,  and  many  of  them,  its  veins,  and  the  veins  returning  its  blood,  are 
greatly  inflamed  and  filled  with  inflammatory  deposits  of  lymph,  or  gorged 
full  of  pus.  Deposits  of  pus  are  also,  in  some  of  the  cases,  found  in  the 
ligamenta  lata,  in  the  womb,  in  the  thorax,  or  in  remote  parts  of  the  body; 
to  such  extent,  indeed,  as  to  have  given  rise  to  the  idea  of  a pyogenic  or 
pus-creating  fever.  The  absorbent  vessels  are  also  found  to  be  affected  in 
a manner  similar  to  that  of  the  veins. 

Diseases  of  childbed  like  these  have  been  noticed  from  time  immemorial 
by  writers  of  great  ability.  Faint  and  imperfect  views  of  their  nature,  and 
some  approaches  to  good  sense  in  their  treatment,  as  by  Strother,  had  been 
obtained,  but  lost  sight  of  again  and  again,  until  a great  reformer  of  doctrine, 


GORDON  ON  PUERPERAL  FEVER. 


667 


as  regards  them,  appeared  in  Scotland.  I allude  here  to  Dr.  Alexander 
Gordon,  of  Aberdeen.*  This  gentleman,  who  enjoyed  an  extensive  prac- 
tice there,  and  in  the  country  round  about  it,  encountered  a severe  epidemic 
of  puerperal  fever,  which,  from  December,  1789,  to  March,  1792,  prevailed 
epidemically  at  and  near  Aberdeen.  The  first  cases  he  treated  without 
energy  and  without  success.  Taught  by  woful  experience  the  inadequacy 
of  his  method,  and  enlightened  by  dissections  of  a few  of  the  early  victims, 
he  adopted  a more  energetic  practice,  which  was  founded  on  the  substantial 
proofs  of  inflammation  revealed  in  the  dissections.  It  consisted  of  free 
bleeding  from  the  arm,  aided  by  the  use  of  purgative  medicines.  The  re- 
sult, to  use  his  own  language,  was  as  follows : “ When  I took  away  only 
ten  or  twelve  ounces  of  blood  from  my  patient,  she  always  died;  but  when 
I had  the  courage  to  take  away  twenty  or  twenty-four  ounces  at  one  bleeding, 
in  the  beginning  of  the  disease,  the  patient  never  failed  to  recover,  as  was 
the  case  in  No.  23,  28,”  &c.  &c.  In  another  place  he  says,  after  citing 
the  results  of  practice  in  other  countries — “ In  my  practice,  of  seventy-seven 
women  who  were  attacked  with  puerperal  fever,  twenty-eight  died  ; so  that 
very  near  two-thirds  of  my  patients  recovered,  which  proves  that  I have 
been  much  more  successful  than  any  other  practitioner.  But  it  will  be  pro- 
per to  mention  that  I was  too  late  in  being  called  to  many  of  the  cases,  and 
that  I had  a fair  trial  only  in  fifty  of  the  above  number:  of  these  fifty,  only 
five  died.” 

Dr.  Gordon’s  volume  is  small,  and  is  written  without  arrogance  or  great 
pretensions.  It  is  a plain  and,  doubtless,  a candid  detail  of  his  concern  with 
that  epidemic ; and  has  so  convincing  and  truthful  an  air  in  every  page  and 
line,  that  I cannot  imagine  any  thing  more  fitted  to  impress  the  mind  of  a 
reader  with  the  warm  and  irresistible  convictions  of  the  author.  Fifty 
years  have  elapsed  since  its  publication.  It  is  always  quoted  or  referred  to 
in  treatises  on  the  same  topic,  and  still  retains  its  good  name.  Every  medi- 
cal practitioner  ought  to  read  it,  and  I was  almost  ready  to  say  that  its  peru- 
sal ought  to  be  regarded  as  indispensably  necessary  to  a right  understanding 
of  the  history  and  treatment  of  puerperal  fever.  Whatever  critics  may  say 
as  to  Dr.  Gordon’s  performance,  and  however  wofully  several  eminent 
writers  and  practitioners  may  have  erred  in  their  theories  and  practice,  Gor- 
don will  be  regarded  as  the  reformer  of  the  therapia  of  puerperal  fever;  for 
it  can  scarcely  be  denied  that,  since  his  publication,  there  is  a more  perfect 
and  understood  conviction  of  the  inflammatory  character  of  this  disorder, 
and  of  the  little  regard  to  be  paid  to  the  state  of  the  pulse  in  making  np 
one’s  mind  as  to  the  necessity  for  treating  it  boldly  in  the  first  stage.  The 
work,  precious  as  it  is,  has  long  been  out  of  print;  and  I cannot  conceal  the 
satisfaction  I feel  at  the  fact  of  its  having  been  placed  at  a cheap  rate  in  the 
hands  of  numerous  practitioners  in  our  country.  M.  Legouais,  in  his  admi- 
rable and  spirited  treatise  on  the  subject,  pays  a just  tribute  to  the  merits  of 

* Author  of  the  History  of  the  Puerperal  Fever  of  Aberdeen.  London,  1795.  8vo. 


668 


PUERPERAL  FEVER. 


this  author;  and,  as  he  had  the  most  abundant  and  fortunate  opportunities, 
by  a residence  of  several  years  in  the  Maternite  at  Paris,  to  witness  the 
practice  and  carry  out  the  directions  of  Chaussier,  in  the  malady,  I should 
conceive  that  his  experience  alone,  unaided  by  the  fine  arguments  of  his 
volume,  should  constitute  him  a high  authority.  -When  I read  Legouais’s 
excellent  work,  I am  disposed  to  thank  Gordon  for  it,  as  I am  for  every  other 
valuable  rule  of  practice  in  this  most  distressing  disease.  Nothing  since 
Gordon’s  work,  that  I have  seen,  detracts  from  his  merit  by  comparison. 
Few  American  physicians  yet  possess  it. 

Gordon  had  not  the  leisure  or  the  privilege  requisite  to  make  very  nume- 
rous and  elaborate  dissections.  This  task,  however,  has  been  well  fulfilled 
by  Robert  Lee,  of  London,  in  his  Treatise  on  Puerperal  Fever  and  Phle- 
bitis; to  that  degree,  indeed,  as  to  leave  but  little  to  be  desired.  All  these 
researches  have  but  added  strength  and  assurance  to  the  conviction  derivable 
from  Gordon’s  essay.  These  new  and  more  minute  inquiries,  which  pro- 
ceed so  much  farther  than  he  had  gone,  ought  to  be  fully  known  by  the 
medical  fraternity.  But  it  will  not  suffice  to  know  only  the  later  productions 
of  the  press.  I do  not  believe  that  the  writings  of  Hey,  of  A.  Baudelocque, 
of  Armstrong,  Mackintosh  and  Lee,  studied  alone,  could  carry  such  a weight 
of  argument  to  the  mind  as  their  perusal  after  Gordon  would  do;  he  is  the 
first  in  the  series,  and  the  others  wait  on  him,  and  honour  themselves  by 
illustrating  him.  Palmam  qui  meruit  ferat. 

It  is  obvious  that  the  death  of  a puerperal  patient  is,  in  general,  more 
to  be  deplored  than  the  ordinary  fatalities  met  with  in  practice.  A wo- 
man, under  these  circumstances,  appears  to  have  a stronger  claim  on  life; 
and  the  disruption  of  the  ties  which  bind  her  to  society,  and  to  her  friends, 
is  more  painful,  from  the  new  relations  just  established  with  them.  If  the 
child  survives,  it  suffers,  during  the  long  period  of  infancy,  childhood  and 
puberty,  the  bitter  fruits  of  this  terrible  privation ; while  the  breaking  up 
of  the  domestic  establishment,  which  usually  follows  that  event,  appeals, 
with  irresistible  power,  to  the  public  sympathy.  Each  family  is  a little  patri- 
archate, state  or  kingdom  ; and  the  domestic  catastrophe  has,  within  its 
proper  pale,  all  the  importance  of  a great  political  overthrow.  It  is  a great 
misfortune  to  lose  a patient  in  childbed. 

Those  diseases,  therefore,  which,  by  their  attacks,  expose  women  to  an 
imminent  danger  of  death  in  childbed,  ought  to  be  carefully  studied  by 
medical  men  ; and  the  physician  should  be  deemed  inexcusable,  who  under- 
takes the  management  of  them  without  a due,  nay,  an  unusually  careful 
preparation  for  the  enterprise.  He  ought  not  to  confide  alone  in  his  own 
keen  perceptions  at  the  clinic,  nor  in  the  results  of  his  own  most  imperfect 
experience.  He  is  obliged,  by  his  vocation,  to  take  up  a position  which  he 
ought  fully  to  examine  and  render  secure  before  he  enters  into  the  conflict 
with  so  dangerous  an  enemy. 

I refer  to  the  statements  in  the  volume  of  Robert  Lee,  for  accounts  of  the 


puerperal  fever. 


669 


mortality  produced  in  some  parts  of  Great  Britain,  and  on  the  Continent, 
by  puerperal  fever.  Those  gentlemen  who,  in  our  own  country,  have  had 
occasion  to  observe  it  either  as  an  epidemic  or  sporadic  disease,  will  require 
no  further  incitement  to  a perusal  of  the  volumes  recently  published  by 
Barrington  & Haswell.  They  will  see  Gordon’s  success,  who,  by  the 
antiphlogistic  treatment,  was  able  to  save  forty-nine  out  of  seventy-seven 
cases;  or,  rather,  forty-live  out  of  fifty;  Hey,  who  met  with  a most  en- 
couraging success  by  the  same  method ; and  Lee,  who  lost  fifty-nine  only 
out  of  one  hundred  and  seventy-two  cases  ; while  Armstrong  saved  all  but 
five  of  his  patients.  In  bespeaking  so  great  a share  of  attention  to  these 
writers,  I do  not  mean  to  disparage  the  opinions  of  others  who  act  upon 
the  same  practical  principles.  I would  refer,  with  especial  satisfaction,  to 
the  opinions  and  experience  of  Dr.  Legouais,  of  David  D.  Davies,  of  Dr. 
Mackintosh,  and  .the  younger  Baudelocque,  for  confirmation  of  the  views 
of  the  gentlemen  whose  works  are  now  republished  in  this  country. 

Let  us  briefly  consider  the  nature  of  the  disorders  usually  comprised 
under  the  term  childbed  fever,  after  taking  a view  of  the  organs  and  tissues 
known  to  be  affected  in  its  different  varieties  and  complications. 

In  the  first  place,  the  gravid  womb  is  a hollow  muscle,  supplied  with  a 
vast  profusion  of  veins,  arteries,  absorbents  and  nerves.  It  would  hardly  be 
deemed  the  stretch  of  a prurient  imagination,  to  compare  it,  on  account  of 
its  great  vascularity,  to  an  enormous  aneurism  by  anastomosis,  furnished  with 
a sufficient  quantity  of  muscular  fibres  to  reduce  back  and  compress,  within 
safe  and  natural  limits,  the  luxuriant  production  of  sanguine  tissues,  of  which 
it  is  chiefly  constituted,  and  which  afford  a proper  nidus  for  the  germ,  which 
derives  from  so  abundant  a source  the  materials  of  its  new  development.  Its 
nerves,  abundantly  distributed  through  its  substance,  and  having  the  most 
intimate  and  complex  connection  with  the  hypogastric,  sacral  and  renal 
plexuses,  and,  indeed,  the  whole  sympathetic  system,  endow  it  with  a nor- 
mal and  pathological  sympathy,  coextensive  with  the  body,  and  a keen 
sensibility  to  both  intrinsic  and  extrinsic  causes  of  excitement. 

Under  the  circumstances  of  such  a physical  constitution,  we  need  feel 
no  surprise  at  observing  the  extent  of  disturbing  force  which,  when  diseased, 
it  exerts  upon  the  whole  economy ; nor,  indeed,  at  the  rapid  destruction  it 
brings  upon  the  living  system,  whenever  it  happens  to  become  the  seat  of 
disorganizing  inflammation. 

The  violent  exertions  of  its  contractile  power,  in  labour,  are  often  alone 
sufficient  to  rupture  or  lacerate  its  tissues,  and,  a.  fortiori , to  injure  or  disease 
them.  It  is  also  liable  to  be  forcibly  and  injuriously  compressed  by  the 
tenesmic  action  of  the  accessory  muscles;  to  be  subject  to  contusions  by  the 
projecting  angles  of  the  foetus  ; or  by  the  bony  sides  of  the  pelvis ; and  to 
be  stimulated  by  the  putrid  discharges  and  absorptions  incident  to  its  lochial 
state.  It  is  connected  by  its  vagina  in  a bond  of  contiguous  sympathies 
propagated  along  that  canal ; which,  even  more  than  itself,  is  subjected  to 


670 


PUERPERAL  FEVER. 


accidents  in  the  parturient  act.  It  is  attached  to  the  ovaries,  which  seem  to 
carry  throughout  pregnancy,  and  even  for  many  months  after  delivery,  an 
invitation  to  disease  in  the  uncured  remains  of  the  corpora  lutea,  and  the 
continued  travail  ovarique,  and  in  which,  it  is  plausibly  supposed,  the  first 
germs  of  some  of  the  puerperal  inflammations  take  their  rise.  It  is  at- 
tached by  the  broad  ligaments  to  the  sides  of  the  pelvis.  These  ligaments 
are  occupied  with  an  abundant  cellular  tissue,  liable  to  infiltrations  and  the 
consequences  of  pressure  and  contusion  and  disruption  in  labour.  It  is  in- 
vested by  a peritoneum  and  a vascular  membrane,  in  which  superficial  in- 
flammation spreads,  with  the  rapidity  of  erysipelas,  over  extended  surfaces. 
This  peritoneum  is  a component  part  of  the  womb — it  is  its  investing 
membrane — its  coat;  and  it  is  also  common,  as  a tissue,  to  the  whole  ali- 
mentary tube,  as  well  as  to  the  liver,  the  spleen,  thq  diaphragm,  the  bladder, 
and  the  abdominal  muscles.  Inflammation  of  the  intestinal,  gastric,  or 
hepatic  peritoneum,  is  also  inflammation  of  those  several  organs;  and,  in 
fine,  a peritonitis  attacking  a childbed  patient,  which  becomes  at  all  exten- 
sive, radiating  from  the  surface  of  the  womb,  soon  involves,  in  its  disastrous 
embrace,  every  important  abdominal  viscus.  Hence  the  tympanites;  hence 
the  constipation  or  the  diarrhoea ; and  hence,  at  last,  and  as  closing  pheno- 
mena, the  nausea,  the  eructations  of  incipient  gastritis,  and  the  last  fatal 
regurgitation  of  the  puerperal  black  vomit.* 

But  not  only  are  the  reproductive  organs  liable  to  be  attacked  by  a simple 
peritonitis  destined  to  extend  far  and  wide ; they  are  the  not  unfrequent 
seats  of  phlebitis  after  labour.  Nor  should  this  liability  excite  any  wonder 
or  suspicion  in  the  mind.  Who  that  has  ever  listened  to  the  rush  of  the 
blood  in  the  uterine  veins,  under  a powerful  contraction  of  that  organ  in 
labour,  but  must  admit  that  the  compression  of  them  in  each  pain  must  do 
violence,  in  a greater  or  less  degree,  to  their  structure;  since,  at  every  return 
of  the  pain,  a major  part  of  the  blood  contained  in  the  veins  and  sinuses  of 
the  organ,  is  hastily  and  forcibly  driven  out  into  collateral  vessels,  to  return 
as  soon  as  the  contraction  ceases,  and  to  be  expelled,  again  and  again,  for 
the  fiftieth  or  the  hundredth  time.f 

The  placental  superficies  of  the  womb,  generally  the  most  vascular  part 
of  the  organ,  is  frequently  left  in  a state  comparable  to  that  of  a wounded 
organ.  Portions  of  the  texture  are  slightly  torn,  or  small  shreds  of  the  pla- 
cental lobules  are  left  adhering,  and  even  the  mouths  of  uterine  vessels  are, 

* Some  of  the  older  writers  have  been  sneered  at  for  supposing  that  childbed  fever 
was  really  an  inflammation  of  the  viscera  of  the  abdomen.  What  else  does  it  prove 
to  bel 

j-  A stethoscope,  or  the  immediate  auscultation  of  the  womb,  during  a labour  pain, 
gives  a very  strong  perception  of  the  violence  and  haste  with  which  the  blood  in  the 
uterine  veins  is  squeezed  out  from  their  cavities ; and  so  great  is  the  apparent  rush 
that  the  sound  is  extremely  disagreeable;  on  account,  I suppose,  of  the  conviction 
that  it  is  so  violent  as  to  compromise,  to  a certain  extent,  the  safety  of  the  tissues 
concerned. 


ri’ERPERAL  EEVER. 


671 


for  days  in  succession,  found  discharging  the  lochial  fluids.  Under  such 
circumstances,  the  veins  inflame  as  do  the  veins  in  an  amputated  limb — the 
frequent  cause  of  death  from  that  surgical  operation  ; and  when  inflamed, 
their  mucous,  or  common  membrane,  like  the  mucous  surface  of  the  larynx 
or  trachea,  soon  begins  to  be  covered  with  inflammatory  or  plastic  exudation; 
it  becomes  thickened,  and  is  the  seat  of  a pyogenic  irritation.  Under  such 
circumstances,  the  future  drainage  of  the  blood  thrown  into  the  organ  by  the 
arteries  is  impeded  or  wholly  suspended.  The  blood  injected  into  the 
womb  through  the  ovarian  and  uterine  arteries,  can  no  longer  freely  pass  off 
by  the  uterine  or  ovarian  veins,  whose  lining  membrane  becomes  the  seat  of 
hasty  and  plastic  inflammation,  which  either  wholly  obstructs  the  tubes,  or 
so  far  diminishes  their  calibre  as  seriously  to  interfere  with  the  passage 
through  the  capillary  and  even  the  larger  vessels. 

The  observations  that  I have  had  opportunities  to  make,  have  led  me  to 
the  conclusion,  that  the  process  of  inflammation,  obstruction,  and  destruction 
of  the  lining  membrane  of  veins,  may  be  hurried  on  with  a celerity  equal 
to  that  of  the  most  rapid  croup.  But  these  changes  of  structure  in  organs 
indispensably  necessary  to  the  constitution  of  the  womb,  imply  as  a conse- 
sequence  its  own  inevitable  destruction  with  that  of  the  patient. 

The  numerous  absorbents  of  the  womb  may  be  viewed  under  the  same 
light,  and  as  being  placed  in  the  same  category. 

Besides  the  above  too  abundant  sources  of  danger  and  evil,  there  is  a great 
liability  to  inflammation  of  the  womb  alone,  and  not  extending  beyond  its 
proper  texture.  This  inflammation,  like  that  in  some  other  tissues,  reduces 
the  womb  almost  to  the  state  of  a pulp,  in  certain  cases,  so  that  it  may  be 
pierced  through  with  the  point  of  a knife,  or  torn  with  the  slightest  force.* 
We  have  seen  instances,  in  which  considerable  portions  of  the  inner,  extend- 
ing nearly  half  way  through  to  the  peritoneal  surface,  have  been  converted, 
within  seventy  or  eighty  hours,  to  a soft  and  gangrenous  material,  almost  fit 
to  be  described  as  a colluvies  or  liquamen. 

Such  diseases  as  these  are  to  be  cured  soon,  or  not  at  all.  It  is  like  a 
battle — “Quid  est!  Concurritur,  et  momento  horae,  aut  cita  mors  venit,  aut 
loeta  victoria.”  If  the  nurse  allow  the  precious  moments  of  the  forming 
stage  to  elapse  before  the  alarm  is  taken ; or  if  the  physician,  through  inat- 
tention or  failure  in  making  the  diagnosis,  pursues,  in  the  beginning,  a feeble 
or  erroneous  practice,  no  human  skill,  sagacity  or  devotion,  can  be  relied 
upon  to  rescue  the  victim,  who  has  already  begun  to  die  before  the  first  hand 
is  extended  for  her  rescue. 

We  hear  and  read  of  numerous  cases  in  which  prompt  measures  have 
been  taken,  of  the  very  class  we  would  recommend,  but  in  vain.  We 
admit  it  has  been  so,  and  it  must  be  so  often  in  future ; for,  unhappily,  the 
greatest  watchfulness  is  sometimes  incapable  of  detecting  the  existence  of  a 

* Robert  Lee  gives  samples  of  this  ramollissement,  or  softening,  of  the  uterine 
texture. 


672 


PUERPERAL  FEVER. 


disease  destined  to  destroy,  because  the  forming  stages — the  curable  ones — 
are  already  overpast  before  the  patient  herself,  much  less  the  nurse  or  the 
physician,  has  perceived  the  least  cause  for  alarm.*  Inflammation  of  the 
lining  membrane  of  a vein  is  not  painful  in  its  commencement;  nor  is 
inflammation  of  the  bronchus  painful  in  its  commencement,  to  a degree  at 
all  commensurate  with  its  dangerous  tendency;  so  that  it  happens,  in  bad 
epidemic  cases,  that  the  attempt  to  cure  fails,  because  the  aid  is  presented 
too  late.  Unquestionable  authority  exists  to  prove,  that  uterine  inflamma- 
tion, in  some  cases,  has  already  gone  far  beyond  any  curable  stage  long 
before  the  delivery  of  the  child  had  permitted  its  existence  to  be  even  sus- 
pected. 

Under  the  above  recited  circumstances,  the  question  is  brought  up — 
What  shall  we  do  for  the  saving  of  the  life  committed  to  our  care,  humanly 
speaking  ? 

Can  we  safely  abandon  the  philosophy  of  medicine,  and,  relying  upon 
some  vague  and  ill-defined  notion  of  a constitutional  depravation,  undertake 
to  counteract  these  vivid  and  almost  electric  movements  of  life,  local  in  their 
origin  and  domain,  by  means  of  a few  drugs  applied  to  the  mucous  mem- 
brane of  the  stomach  or  bowels;  by  some  cataplasms  or  liniments,  or 
fomentations  to  the  belly;  or,  at  most,  by  dozens  or  hundreds  of  leeches 
fixed  on  the  cutis  of  the  abdomen  ? What  are  great  inflammations,  that 
they  can  be  overcome  by  such  means;  especially  inflammations  concealed 
in  the  very  recesses  of  the  body,  remote  from  the  surfaces,  and  deriving 
their  source,  their  impetus,  their  proximate  cause,  their  ipsissima  'causa 
from  the  injecting  power  of  arteries  springing  directly  from  the  emulgents, 
the  aorta,  or  the  hypogastric  tubes  ? It  would  appear  to  me  to  be  mere 
dawdling  with  the  malady,  in  comparison  with  the  vigorous  and  masterful 
influences  of  blood-letting,  which  is  perfectly  obedient  to  the  will  of  the 
physician,  goes  directly  to  its  object,  and  stops  short  at  the  desirable  point: 
which  reduces  the  injecting  force  of  the  systemic  ventricle,  and  brings  it  to 
such  a state  as  to  leave  the  necessary  equipoise  between  all  the  parts  of  the 
angiotenic  apparatus:  a therapeutic  agent,  which,  wisely  and  well  directed 
to  the  exigencies  of  the  case,  surpasses  all  other  modes  of  relief  or  cure. 

In  the  application  of  this  great  measure  for  the  cure  of  these  puerperal 
inflammations,  I might  feel  content  to  refer  to  the  exhortations  of  Gordon, 
to  be  firm  and  decided;  and  I trust  that  every  one  of  my  medical  brethren 
who  may  read  his  book,  will  give  due  weight  to  his  energetic  expressions 
on  that  point.  But  I cannot  resist  the  desire  I feel  to  remark,  that  a feeble 

* I am  disposed  to  believe,  from  opportunities  recently  enjoyed,  that  even  the  con- 
stitution of  the  patient  does  not  take  the  alarm  in  some  examples  of  phlebitis,  until 
the  disease  has  already  reached  a certain,  stage  of  development,  at  which  it  is  in- 
curable. This  is  undoubtedly  the  case  in  certain  cases  of  crural  phlebitis — where 
our  attention  is  called  to  a state  of  the  limb,  just  discovered  by  the  patient,  and 
which  must  have  already  existed  many  hours  before  she  herself  detected  or  even 
suspected  any  disorder. 


PUERPERAL  FEVER. 


673 


and  timid  employment  of  the  measure  will  be  likely,  not  only  to  fail  of 
success,  but  even  to  give  additional  impetuosity  to  the  disorganizing  forces 
of  the  malady.*  The  pulse,  under  certain  circumstances  of  constitutional 
irritation,  is  found  to  be  in  the  state  which  Dr.  Rush  characterized  as  the 
oppressed  pulse, — a pulse  in  which  the  beat  is  apparently  feeble,  and  ren- 
dering it  doubtful  whether  a safe  recourse  is  to  be  h-ad  to  the  lancet;  but 

which,  after  the  abstraction  of  a certain  quantity  of  blood,  rises  and  bounds 

like  the  full  synochus  fortis  action.  To  raise  the  pulse  to  this  condition,  and 
leave  it  so,  is  to  disengage  the  heart — the  injecting  power — from  something 
that  obstructed  and  embarrassed  its  action;  and  to  enable  it,  by  setting  it  at 
liberty,  as  it  were,  to  force  new  and  greater  torrents  of  blood  into  the 
inflamed  parts,  impacting  it  there,  and  extending  the  inflammatory  engorge- 
ments and  obstructions  into  the  collateral  capillaries  in  every  direction. 
Hence  it  is  apparent,  that  in  using  venesection'  as  a remedy,  it  will  not 

suffice  to  stop  as  soon  as  the  pulse  has  risen : it  must  be  carried  to  the 

extent  of  subduing  and  reducing  down  within  safe  limits  the  power  which 
it  is  instituted  to  control. 

If  there  be  any  thing  true  in  medical  philosophy,  it  is  that  all  the  nervous, 
muscular,  and  nutritive  functions,  have  a very  close  dependence  upon  the 
circulation  of  the  blood.  An  increase  of  the  momentum  of  the  blood  tends 
to  augment  the  development  of  the  nervous  force  ; every  organ  is  stimulated 
and  brought  to  a higher  degree  and  expression  of  vital  power  by  increased 
rapidity,  within  certain  limits,  of  the  blood’s  motion.  On  the  contrary, 
diminished  intensity  of  its  motion  tends  to  diminish  the  innervative  force, 
with  all  the  action  of  all  the  organs  dependent  on  that  force.  To  bleed  in 
fevers  and  inflammations,  is  to  lessen  them.  But  the  question  is,  not  as 
to  bleeding;  it  is  as  to  how  much?  by  what  sign  shall  we  know  when  to 
stop?  Is  there  a safe  limit? 

What  is  that  safe  limit?  The  practitioner  is  the  sole  judge.  It  is  easy  to  stop 
short  of  its  attainment:  it  is  by  no  means  difficult,  nor  perhaps  uncommon,  to 
go  beyond  it ; and  thus  render  most  injurious  a means  designed  only  for  good. 
Experience  is  the  only  teacher : the  physician  must  have  acquired  that  fami- 
liarity with  the  condition  of  the  pulse,  in  health  and  disease,  that  can  alone 
enable  him  to  say — this  is  sufficient ; the  movement  of  the  circulation  is  now 
no  longer  destructive  or  dangerous  ; the  columns  of  blood  driven  through  the 
arterial  tubes  upon  the  inflamed  tissues,  reach  them  with  a force  sufficiently 
moderate  to  permit  them  to  recover.  Experience,  habit,  tact,  sagacity,  these 

* There  is  great  difficulty,  except  in  the  clearest  cases  of  violent  reaction,  in 
bringing  one’s  mind  to  the  point  of  courage  so  anxiously  inculcated  by  Gordon,  and 
which  it  seems  he  himself  found  it  hard  to  attain.  Let  the  reader  of  his  book 
ponder  well  his  directions;  and  if  they  meet  the  concurrence  of  his  judgment,  let 
him  bear  them  in  mind  at  the  clinic. — “ Jugulare  febrim ” should  be  the  motto  in 
such  cases. 

43 


674 


PUERPERAL  FEVER. 


will  govern  him,  and  show  him  that  he  can  go  no  further  with  safety.  Gor- 
don insists  upon  twenty-four  ounces  as  the  quantity  to  be  drawn  in  the  early 
stage — within  twenty-four  hours  of  the  attack — and  he  looked  with  confi- 
dence to  a cure  when  that  quantity  could  be  drawn.  I find  no  objection  to  his 
standard,  which  is  concurred  in  by  Hey,  with- certain  exceptions.  It  is  pro- 
bably sufficiently  large  to  effect  the  desirable  degree  of  reduction  in  most 
cases,  but  I should  not  be  willing  to  adopt  it  as  a universal  rule,  since 
there  are  many  constitutions  that  would  bear  a greater  abstraction  than  he 
proposes  without  injury,  while  others  would  not  endure  to  lose  near  so 
much  without  a fall  of  the  rate  of  circulation  below  the  desirable  point: 
the  same  point,  in  a word,  being  attainable  in  some  by  twenty-four  ounces, 
in  others  by  not  less  than  thirty,  and  in  others,  again,  by  twelve  or  fifteen. 
Let  the  pulse  declare;  let  the  breathing  declare;  let  the  cessation  of  pain 
declare;  let  the  general  sensations  of  the  patient  declare:  while  her  voice, 
gesture,  decubitus , and  physiognomonic  expression,  concur  in  indicating 
that  enough  has  been  done,  and  not  too  little,  nor  too  much. 

There  is  not,  and  there  cannot  be,  any  safety  in  practising  physic  by  a 
rule.  The  state  of  the  case  ought  always  first  to  be  made  out  and  under- 
stood ; the  physiological  rate  of  the  parts  concerned  in  disease  should  be 
detected,  as  well  as  the  epiphenomena  which  the  prime  disorders  have 
superinduced ; and  from  this  knowledge  should  be  collected  the  indications 
of  cure,  and  the  precise  agents  to  be  used  in  the  process  determined  upon. 
The  innervation,  the  circulation,  and  the  respiration,  compose  the  great  triad 
of  the  offices  of  the  constitution:  all  constitutional  disorders  must  implicate 
one  or  more  of  them.  Let  the  physician  take  care  that  these  suffer  no  material 
detriment  in  the  case,  and  the  remaining  functions,  that  are  of  greater  or  less 
vital  importance,  will  be  all  the  safer  for  the  wise  precautions  he  may  take 
as  to  these  principal  ones.  Death  must,  in  every  instance,  depend  upon  the 
cessation  of  vital  action,  either  in  the  brain,  or  heart,  or  lungs,  according  to 
the  beautiful  exposition  of  Bichat;  no  man  can  die  but  by  one  of  these 
powers.  Let  the  medical  attendant,  then,  in  his  plan  for  the  treatment  of 
such  grave  disorders  as  those  under  consideration,  adapt  his  measures  to 
the  conservation  or  rectification  of  these  functions.  I say  again,  then,  let 
the  pulse  declare;  let  the  breathing  declare;  let  the  pain,  the  decubitus , the 
expression,  &c.,  all  concur  in  declaring  what  he  ought  to  do,  and  teach  him 
that  he  is  about  to  do,  or  has  done,  right ; neither  too  little,  nor  too  much. 

There  is  a valuable  work  by  Dr.  Legouais,  published  in  4to.,  Paris,  1820. 
It  is  entitled,  “ Reflections  and  Observations  on  the  Employment  of  Bleed- 
ing and  of  Purgatives  in  the  Treatment  of  Puerperal  Fever."  This 
gentleman  appears  to  have  had  a very  enlarged  field  for  observation  on  the 
subject  in  question,  and  claims,  with  apparent  justice,  to  be  heard  on  the 
topic.  He  sets  forth  (p.  12)  the  evidences  which  go  to  prove  that  the  dis- 
ease is  an  inflammation. 

He  says: — To  acknowledge  that  the  disorder  most  common  to  lying-in 


PUERPERAL  FEVER. 


67  5 


women  is  an  inflammatory  one,  is  to  admit  that  sanguine  evacuations  must 
constitute  an  essential  part  of  its  treatment.  We  cannot  avoid  the  adoption 
of  such  a proposition : its  truth  is  demonstrated  to  us ; and  we  have  on  this 
point  the  highest  degree  of  conviction  that  can  be  attained  in  medicine. 
But  we  are  far  from  admitting  this  without  qualification ; and,  however  great 
may  be  the  acknowledged  utility  of  venesection  in  puerperal  peritonitis,  as  a 
general  proposition,  it  appears  to  us  equally  important  that  its  employment 
should  be  subjected  to  certain  rules  in  order  to  ensure  its  success  : without 
such  rules  even  venesection,  instead  of  proving  useful,  becomes  injurious  in 
the  disease,  (p.  17.) 

Dr.  L.  thinks,  that  venesection  is  applicable  to  the  first  stage,  or  stage  of 
irritation ; and  that,  when  the  inflammatory  movement  has  gone  so  far  as 
clearly  to  indicate  to  what  termination  it  tends,  the  use  of  blood-letting 
serves  only  to  derange  the  action  or  hasten  that  result,  whatever  it  may  be. 
He  admits  that  the  duration  of  this  stage  may  be  very  different  in  different 
subjects:  the  medical  attendant  is  to  judge  of  the  duration,  (p.  17-18.) 

He  contends  that  this  stage  does  not  extend  beyond  twenty-four  hours, 
and  that  he  has  never  seen  any  good  result  from  it  at  a later  day,  except  in 
a very  small  number  of  cases ; and  even  in  these  the  abstractions  have 
been  so  small  in  quantity  as  to  leave  room  to  doubt  of  their  influence,  if 
any.  (p.  19.) 

The  paragraph  commencing  at  p.  21  is  devoted  to  the  question,  as  to  the 
quantity  of  blood  to  be  taken ; which,  Dr.  L.  insists,  should  be  large  enough, 
jugulare  febrim , as  Galen  says,  to  destroy  it  at  a blow,  and  not  merely  to 
weaken  the  force  of  the  disease  for  a short  period,  in  order  that  it  may 
rise  with  greater  power  in  a system  weakened  and  not  saved  by  the  first 
operation.  He  finds  the  fault,  generally  found  with  Leake,  who,  under- 
standing the  nature  of  the  case  well,  and  urging  early  and  free  blood-letting, 
yet  did  not  himself  go  beyond  eight  or  ten  ounces. 

Again: — “We  believe,  then,  that  in  treating  puerperal  fever  by  blood- 
letting, the  object  should  be  to  abolish  the  disease  entirely  by  the  powerful 
and  energetic  use  of  the  remedy.  It  is  the  fabulous  hydra,  which  can  only 
be  destroyed  by  cutting  off  at  a blow  all  the  heads.  If  a single  one  be 
spared,  it  is  sufficient  to  keep  alive  a vital  principle,  which  soon  reproduces 
the  monster  more  terrible  than  before.”  (p.  23.) 

In  a paragraph,  at  p.  24,  he  regards  the  quantity  needful  as  eighteen, 
twenty,  or  twenty-four  ounces  at  the  first  operation ; less  than  this  rarely 
produces  an  advantageous  and  sure  result. 

The  student  of  the  history  of  childbed  fever  will  not  have,  failed  to  ob- 
serve, that  many  individuals  of  the  profession  who  have  been  called  upon  to 
encounter  the  disease  in  question,  when  it  prevailed  as  an  epidemic,  have 
trusted  to  the  use  of  remedies,  which,  although  not  successful  in  curing  the 
disorder,  or  saving  the  patient  from  death,  yet  could  not  be  accused  of  mis- 
chievous or  pernicious  action  in  the  case.  This  arises  from  the  less  obvious 


676 


PUERPERAL  FEVER. 


or  less  evident  nature  of  the  operation  of  drugs  than  of  venesection,  which 
produces  effects  so  sudden  and  palpable  upon  the  great  vital  functions,  as  to 
render  them  intelligible  to  the  ordinary  by-standers  and  friends.  A patient 
taking  large  doses  of  calomel  or  James’s  powder,  or  ipecacuanha,  or  purga- 
tives, if  she  grows  worse  and  worse  in  childbed  fever,  will  be  readily  sup- 
posed to  do  so,  notwithstanding  the  salubrious  tendencies  of  their  operations: 
Post  hoc , sed  non  propter  hoc.  Whereas,  should  she  decline  as  rapidly 
under  the  use  of  the  lancet,  that  decline  is  apt  to  be  charged  directly  to  the 
loss  of  blood.  Dr.  Robert  Collins,  of  Dublin,  in  his  Practical  Treatise  on 
Midwifery  * says,  that  of  the  eighty-eight  cases  which  he  had  under  his 
care  while  Master  of  the  Dublin  Lying-in  Hospital,  thirty-two  recovered, 
and  fifty-six  died.  (p.  190.) 

Dr.  Collins,  in  this  important  work,  discourages  the  use  of  venesection 
in  the  epidemic  forms  of  the  disorder.  Let  it  be  observed,  however,  that  he 
had  eighty-eight  cases,  of  which  fifty-six  died,  and  thirty-two  recovered. 
He  says,  “In  fifteen  only  of  the  eighty-eight  did  we  deem  it  advisable  to 
bleed  generally;  seven  of  the  fifteen  recovered.”  Notwithstanding  this,  the 
doctor  gives  the  following  summary  : — “ The  result  of  my  observations  upon 
the  treatment  of  puerperal  fever  is,  that  general  bleeding,  except  when  there 
is  a strong,  full  pulse,  and  the  symptoms  are  of  a highly  inflammatory  cha- 
racter, is  injurious.  On  the  contrary,  local  depletion,  by  the  application  of 
three  or  four  dozen  leeches,  followed  by  the  warm-bath  and  stuping,  all  of 
which  should  be  repeated  according  to  circumstances,  and  as  often  as  the 
strength  will  permit,  seemed  most  beneficial.  These  means,  together  with 
the  active  employment  of  calomel,  conjoined  with  hippo  or  opium,  offer  the 
best  prospect  of  relief.  Blistering  the  whole  abdomen,  after  leeching  had 
been  pushed  as  far  as  could  be,  was  found  serviceable.  In  some  cases  the 
debility  was  so  excessive  as  to  induce  us  to  apply  the  blister  at  once,  using 
calomel  and  stimulants  at  the  same  time.”  (p.  396.) 

Dr.  Collins  evidently  entertains  the  opinion,  adverse  to  my  own,  that 
puerperal  fever  is  a something  over  and  above  the  local  disease,  and  consti- 
tutional affection  resulting  therefrom.  In  this  opinion  he  has  many  sup- 
porters. But,  accustomed  to  look  for  causes  sufficient,  and  not  more  than 
sufficient,  for  the  production  of  certain  effects,  I find  myself  still  unable  to 
believe  that  he  and  those  who  think  with  him  are  right.  Phlebitis  of  the 
recently-discharged  womb  is  alone  sufficient  to  produce  all  the  frightful 
rapidity  of  which  Dr.  Collins  speaks — so  is  gangrenous  inflammation  of  the 
inner  paries  of  the  organ  ; and  equally  capable  of  causing  a rapid,  a most 
sudden  overthrow  of  all  the  functions,  is  an  inflammation  of  the  whole  peri- 
toneum ; by  which  is  implied,  as  I have  before  explained,  a disease  of  every 
organ  which  receives  an  investment  of  the  peritoneal  membrane  as  part  and 
parcel  of  its  own  nature  and  texture. 

I cannot  but  avow,  that  so  great  is  the  respect  I feel  for  Dr.  Collins,  of 

* Select  Medical  Library,  February,  1838,  Philadelphia,  Barrington  & Haswell. 


PUERPERAL  FEVER. 


677 


Dublin,  on  account  of  the  very  valuable  services  he  has  rendered  to  man- 
kind, and  particularly  to  the  medical  profession,  in  giving  to  them  the  work 
above  quoted  from,  that  it  is  with  much  reluctance  I find  myself  compelled 
to  dissent  from  his  opinions  on  puerperal  fever.  Acknowledging,  therefore, 
his  great  authority  as  a medical  teacher,  I disavow  it  for  his  article  on  puer- 
peral fever;  in  which  neither  does  his  reasoning  take  captive  my  judgment 
by  its  force,  nor  his  practice  overcome  my  prejudices  by  its  success;  in 
fact,  its  success  was  very  bad — he  having  lost  nearly  two  out  of  three  cases  ; 
and  his  reasoning  not  better,  since  it  is  founded  on  the  bare  postulate,  that 
the  disease  was  something  more — something  beyond  inflammation  of  tissues ; 
an  opinion  which,  were  it  even  proved  to  be  true,  could  not  alter  my  views 
of  the  urgent  necessity  to  reproduce  the  reciprocity  of  force  betwixt  the 
receiving  or  inflamed  tissues  and  the  injecting  agent,  viz.,  the  heart  and 
arteries. 

I am  further  compelled  to  dissent  from  Dr.  Collins’  authority,  and  that  of 
those  who  agree  with  him,  in  regard  to  the  preferableness  of  leeching  to 
direct  blood-letting  from  veins.  I have  never  yet  perceived  the  full  force  of 
the  reasoning  which  induces  many  medical  practitioners  to  prefer  local  to 
general  bleedings  in  such  great  cases.  The  mere  fact  that  the  leech  draws 
blood  from  the  cutis  of  the  abdomen,  ought  not  to  be  taken  as  proof  that  it  is 
capable  of  exhausting  a system  of  non-collateral  vessels  in  the  interior  of  the 
body.  What  direct  connection  can  be  asserted  to  exist  betwixt  the  capillaries 
of  the  skin  and  those  of  the  intestinal  peritoneum;  or  the  uterine  veins,  or 
absorbents,  or  the  proper  texture  of  the  womb  ? The  abdominal  peritoneum 
and  the  intestinal  peritoneum  are  in  all  probability  equally  exempt  from  the 
charge  of  originating  or  setting  on  foot  the  first  movements  of  the  inflamma- 
tion in  childbed  fever.  But  the  womb  and  its  annexed  organs  are  supplied  from 
the  ovarian  and  the  uterine  arteries.  This  circulation  is  in  nowise  directly  re- 
lated to  the  circulation  in  the  skin.  Hence  I infer,  if  the  leeching  is  useful  in 
this  case,  it  is  through  its  power  on  the  action  of  the  heart  alone,  and  not  by  an 
immediate  depletion  of  the  inflamed  parts.  But  if  the  object  in  truth  be,  to 
modify  the  injecting  power  of  the  heart,  by  diminishing  the  quantity  of  the 
blood  and  changing  its  crasis,  why  not  take  it  from  a vein  at  once,  where 
you  can  control  the  operation?  where  you  can  take  one  ounce  or  twenty? 
where  you  can  go  on  or  stop  at  the  slightest  warning?  and  where  you  avoid 
all  the  fatigue  and  exposure  to  cold  and  dampness  inseparable  from  the  ope- 
ration of  leeching?  A patient  who  can  bear  leeches  can,  in  general,  much 
better  tolerate  the  lancet.  I shall  be  glad,  therefore,  when  the  day  arrives 
in  which  the  therapeutical  employment  of  the  leech  should  be  understood 
as  nearly  confined  to  local  disorders  ; while  the  lancet  should  be  esteemed 
as  applicable  for  both  the  local  inflammations  and  engorgements,  and  the 
constitutional  derangements  either  arising  out  of  them,  or  originating  them. 

Dr.  Baudelocque,  the  younger,  in  his  Traite  tie  la  Peritonite  Puerperale , 
cites  opinions  from  the  Diet . des  Scien.  Med.  unfavourable  to  the  use  of 


678 


PUERPERAL  FEVER. 


general  bleeding  except  in  special  cases,  but  highly  laudatory  of  the  employ- 
ment of  leeches  as  a means  of  cure.  Dr.  B.  opposes  the  sentiments  of  that 
party  as  follows  : — 

“ It  has  been  further  alleged  in  favour  of  leeching,  that  in  drawing  blood 
from  the  capillary  system  they  are  also  able  to  abstract  it  directly  from  the 
diseased  organ,  by  means  of  vascular  connections  existing  betwixt  the  skin 
and  the  subjacent  parts.  This  communication  seems  to  me  to  be  remote 
even  in  the  case  of  inflammation  of  that  portion  of  the  peritoneum  that  lines 
the  anterior  parietes  of  the  abdomen ; and  it  must  be  absolutely  null  when 
the  inflammation  is  seated  in  the  broad  ligaments,  upon  the  womb,  upon 
the  intestines,  &c.,  which  is  most  commonly  the  case.”  (p.  330.) 

“ I do  not  participate  in  the  fears  of  MM.  Gasc  and  Marat,  as  to  the  dis- 
advantages of  general  bleedings  ; and  cannot  place  the  same  confidence  that 
they  do  in  topical  depletion.  Whenever  a loss  of  blood  is  indicated,  and 
properly  administered,  a venesection  is  not  more  likely  to  promote  the  deve- 
lopment of  an  adynamia  than  a leeching;  if,  on  the  contrary,  the  loss  of 
blood  is  contra-indicated,  the  employment  of  leeches,  it  is  true,  will  do  less 
harm  than  that  of  the  lancet,  but  we  ought  not  to  select  one  remedy  in  pre- 
ference to  another  because  it  will  do  less  injury  to  the  patient  than  that  other.” 

A little  further  on  he  speaks  in  the  following  terms  : — “ In  my  opinion, 
bleeding  from  the  arm  is,  in  the  majority  of  cases,  to  be  preferred  to  leeching; 
and  that  the  latter  should  be  resorted  to  only  where,  after  having  obtained 
by  venesection  a considerable  diminution  of  the  symptoms,  there  remain 
several  painful  points  in  the  abdomen.  These  points  should  be  covered 
with  leeches,  which  will  then  dissipate  a disorder  for  which  general  bleeding 
would  have  been  much  less  efficacious.  In  weakly  persons  it  would  be 
proper  to  use  the  leeches  at  once,  especially  if  the  inflammation  should  be 
partial,  of  small  extent,  and  accompanied  with  but  little  fever.  But  they 
should  be  used  in  pretty  great  numbers : it  is  not  by  applying  eight  or  ten 
leeches  that  advantage  may  be  expected ; — twice  or  thrice  this  number 
should  be  put  on.  A fortiori , the  number  should  be  much  more  considera- 
ble, where,  from  peculiar  circumstances,  we  are  obliged  to  abstain  from 
general  bleeding  in  a robust  person,  and  confide  in  leeches  alone  for  the 
cure  of  the  peritonitis ; in  such  case  we  ought  to  use  fifty  or  sixty  each 
time.”*  (p.  333.) 

In  the  above  views  of  M.  B.  I do  not  perceive  how  any  one  can  fail  to 
eoncur.  It  seems  to  me  that,  except  for  purely  local  affections,  the  loss  of 
blood  ought  to  be  effected  from  a vein  of  considerable  size,  in  order  to  bring 
about  a state  of  the  whole  circulation  favourable  to  the  termination  by  reso- 
lution. I have  had,  as  I think,  many  occasions  of  observing,  that  where 
leeches  were  applied  for  the  relief  of  great  and  extensive  inflammations, 

* The  reader  will  bear  in  mind  the  greater  powers  of  the  French  over  the  Ameri- 
can leech. 


PUERPERAL  FEVER. 


679 


attended  with  much  constitutional  perturbation,  they  rather  served  to  weaken 
the  patient  than  to  diminish  the  force  of  the  disorder. 

Nor  is  it  at  all  apparent  to  me,  that  even  in  those  cases  where  leeching  is 
practised  to  the  extent  of  bringing  on  a disposition  to  syncope,  any  advan- 
tages superior,  or  even  equal,  to  those  derivable  from  venesection,  can  be 
claimed.  The  debility  occasioned  by  leeching  ad  deliquium  animi  has 
always,  under  my  observation,  been  alarming,  and  even  dangerous.  It  is 
much  less  easily  recovered  from  than  in  the  case  of  its  following  phlebotomy. 

Dr.  Mackintosh,  a writer  of  great  reputation,  in  his  Principles  of  Patho- 
logy and  Practice  of  Physic  gives  a few  pages  to  the  subject  of  puerperal 
peritonitis;  and  it  is  true  that,  at  p.  201,  edition  of  1834,  he  bestows  much 
praise  on  the  employment  of  leeches  in  the  case.  Nevertheless,  his  views 
are  conformable  to  those  of  Gordon,  Hey,  Armstrong,  &c.,  in  regard  to 
the  greater  dependence  to  be  placed  on  venesection,  as  may  be  seen  in  his 
summary  at  p.  202,  and  in  his  critical  and  sarcastic  remarks  upon  Dr. 
Hamilton.  It  is  perhaps  useless  to  multiply  citations  here;  and,  indeed, 
I am  quite  willing  to  leave  the  decision  to  the  judgment  of  any  practitioner 
who  will  give  due  regard  to  the  arguments  drawn  from  the  nature  and  ex- 
tent of  the  disorder,  the  indications  of  treatment,  and  the  comparative  powers 
and  facilities  of  the  several  remedies. 

There  are  writers  who  disapprove  of  frequent  repetitions  of  venesection  in 
the  treatment  of  puerperal  fever ; as,  for  example,  Legouais,  above  quoted.  I 
have  already  said  that  it  is  not  difficult  for  the  approvers  of  venesection  to 
carry  the  abstraction  of  blood  too  far.  I know  that  in  some  cases,  when  it  has 
been  deemed  needful  to  bleed  very  copiously  for  the  cure  of  an  inflammatory 
attack,  the  latter  part  of  the  case  has  been  rendered  very  unmanageable  by 
the  supervention  of  a state  of  the  pulse,  which  may  be  qualified  by  the  epi- 
thet soap-bubble,  from  its  slight  resistance  to  pressure,  notwithstanding  the 
considerable  remaining  volume  of  the  radial  artery.  Such  a pulse  is  fre- 
quently met  with  after  very  violent  uterine  haemorrhages  ; and  is  not  unapt 
to  mislead  the  inexperienced  by  its  apparent  vehemence,  when,  in  fact,  it 
arises  from  the  insufficient  stimulation  of  the  heart  and  brain,  the  conse- 
quence of  a diminished  crasis  of  the  blood.  The  blood,  for  its  healthful 
constitution,  requires  a due  proportion  of  crassamentum,  from  which  it 
derives  its  proper  crasis.  While  I am  aware,  on  the  one  hand,  that  the 
constitution  of  the  blood  may  be  seriously  changed  by  the  imprudent  repe- 
tition of  phlebotomy,  I am  not  afraid  to  repeat  the  venesections  in  peritoni- 
tis, &c.,  until  I feel  assured,  both  from  the  state  of  the  crassamentum  and  the 
signs  presented  by  the  patient,  that  no  more  can  be  taken  with  prospect  of 
benefit  to  the  patient.  To  show  what  can  be  borne  in  certain  cases,  let  me 
relate  the  following  observation.  In  the  course  of  the  present  year  a case 
fell  under  my  care,  of  which  the  following  is  a correct  statement: — A young 
married  lady,  at  the  end  of  her  fourth  pregnancy,  was  attacked  about  3 A.  M. 
with  pains  of  labour  and  flooding.  I did  not  see  her  until  mid-day.  Upon 


G80 


PUERPERAL  FEVER. 


arriving  at  the  house,  I judged,  upon  careful  inspection  of  the  napkins  and 
sheets,  &c.,  that  had  been  removed  from  about  her  person,  that  she  had  lost 
fifty  ounces  of  blood ; an  opinion  strengthened  by  an  examination  of  her 
pulse,  her  muscular  strength,  and  her  skin,  which  was  excessively  pale. 
Upon  making  an  examination  I found  the  haemorrhage  still  active;  and,  in 
order  to  check  it,  resolved,  as  the  placenta  was  not  in  jeach,  and  the  os  uteri 
one-third  dilated,  to  rupture  the  membranes,  according  to  the  method,  as  it 
is  called,  of  Louise  Bourgeois.  As  soon  as  the  water  had  gone  off,  the 
haemorrhage  was  stayed ; and  she,  not  long  afterwards,  gave  birth  to  a 
healthy  child.  The  young  lady  was  very  weak.  I saw  her  late  in  the 
evening,  and  she  was  comfortable,  but  extremely  pale.  During  the  course 
of  the  next  day  and  night  she  was  comfortable,  and  was  kept  carefully  in 
bed,  being  without  other  complaint  than  debility.  But  at  4 o’clock  in  the 
morning  she  was  attacked  with  intense  rigor,  amounting  to  ague,  accompa- 
nied by  excessive  pain  and  soreness  of  the  belly,  with  a pulse  at  150  per 
minute,  rising  at  times  to  160  beats;  she  presented,  indeed,  all  the  pheno- 
mena of  a violent  attack  of  puerperal  fever.  I did  not  see  this  patient  until 
as  late  as  1 1 a.  m. 

Upon  making  out  the  diagnosis,  I again  made  inquiries  of  her  mother,  a 
most  intelligent  person,  who  convinced  me  that  the  first  estimate,  as  to  the 
quantity  lost  in  the  haemorrhage,  was  far  too  small ; and  I have  not,  at  this 
moment,  any  doubt  of  her  having  lost,  on  that  day,  full  seventy  ounces  of 
blood.  As  puerperal  fever  was  prevailing  considerably  at  the  time,  I felt 
deeply  concerned  as  to  the  line  of  my  duty  in  the  actual  circumstances.  It 
appeared  to  me  more  than  probable,  considering  the  violence  of  the  attack 
after  so  great  a haemorrhage,  that  it  would  prove  fatal  under  any  treatment 
that  might  be  adopted.  I thought  it  certainly  would  have  a fatal  result, 
should  I allow  the  heart  to  continue  beating  at  so  violent  a rate.  150  pulsa- 
tions per  minute  will  give  115,200  pulsations  per  diem  over  and  above  the 
number  required  for  the  healthful  rate  of  the  circulation;  which,  at  seventy 
per  minute,  gives  a little  over  100,000  per  day.  Let  any  one  conceive  the 
amount  of  danger  and  mischief  concomitant  upon  the  long  continuance  of 
such  an  excessive  rate  of  a vital  function.  But  the  patient  had  already  lost 
profusely  of  her  blood  ; and  hence,  with  due  regard  for  my  own  reputation, 
or  the  credit  of  a most  invaluable  remedy,  could  I venture  to  increase  this 
loss  by  bleeding  her,  whose  death,  probably,  under  such  treatment,  would  be 
boldly  charged  to  malpractice?  It  was  a severe  struggle;  but  I had  convic- 
tion enough  to  compel  me  to  follow  the  suggestions  of  mv  judgment;  and 
having  bled  her  as  freely  as  I dared  to  do,  I had  the  satisfaction  to  find  that 
the  pulse  soon  fell  to  a more  moderate  state,  and  in  forty-eight  hours  my 
patient  was  out  of  danger,  and  is  now  enjoying  health,  and  a life  which, 
I sincerely  think,  would  have  been  destroyed  by  metro-peritonitis,  but  for 
the  correct  decision  I made  as  to  the  use  of  the  lancet. 

I have  recited  the  above  case  as  evidence  of  the  propriety  of  bleeding  a 


PUERPERAL  FEVER. 


681 


patient,  notwithstanding  she  has  already  lost  freely  of  her  blood  ; and 
numerous  instances  have  fallen  under  my  notice  where  venesection  has  been 
reiterated  during  successive  days  after  the  attack  was  fully  formed.  In  the 
winter  of  1840,  I visited  the  wife  of  a gentleman  at  Concord,  twenty  miles 
from  the  city,  who  had  been  three  days  ill,  under  the  care  of  a neighbouring 
physician.  The  latter  had  bled  her  once,  but  sparingly,  on  the  second  day, 
though  she  was  labouring  under  severe  peritoneal  fever.  Upon  arriving  in 
the  night,  at  her  residence,  where  I met  the  medical  gentleman,  we  con- 
curred in  opinion  as  to  the  propriety  of  another  venesection,  which  was 
promptly  effected,  and  repeated  the  next  day,  and  then  followed  by  cupping 
of  the  belly  ; so  that  she  perfectly  recovered  after  a very  narrow  escape.  In 
the  lying-in  wards  of  the  Pennsylvania  Hospital,  I have  seen  seven  women 
recover  from  the  most  alarming  attacks  of  metro-peritonitis,  under  the  vigor- 
ous employment  of  the  lancet,  carried  to  the  full  extent  of  Gordon’s  views; 
not  a single  death  has  taken  place  there,  under  this  treatment,  within  my 
notice.  I shall  recite  the  following  sample  from  my  note-book,  which  may 
suffice  to  show  more  clearly  my  views  of  the  plan  that  ought  to  be  followed. 

Mrs.  W.  G.,  aged  about  twenty  years;  first  pregnancy;  was  delivered 
on  Thursday,  the  4th  November,  1830,  of  a female  child,  after  a labour  of 
four  hours. 

She  was  very  comfortable  on  Friday  and  Saturday.  There  was  already 
a small  quantity  of  milk  in  the  breasts,  but  they  were  neither  full  nor  pain- 
ful. The  bowels  were  opened  on  Saturday  by  a dose  of  castor  oil,  a table- 
spoonful and  a half,  which  operated  through  the  day  and  night  ten  or  twelve 
times.  She  has  had,  for  her  diet,  tea  and  bread,  and  oatmeal  gruel.  There 
was  no  fever  on  Friday  nor  Saturday. 

Sunday , November  7th. — I did  not  call  to  see  her  until  past  10  a.  m.  She 
had  had  a chill  in  the  night,  rested  badly,  and  now  suffers  pain  and  soreness 
in  the  right  flank  and  iliac  region.  The  parts  were  very  tender  on  pressure, 
distended  and  resonant  under  percussion  ; the  fundus  uteri , above  the  sym- 
physis pubis,  sore  to  the  touch ; lochia  bright  and  free;  urine  abundant; 
tongue  whitish,  soft,  moist  and  broad;  headache,  thirst,  dorsal  decubitus; 
motion  of  thighs  gives  pain  in  abdomen;  any  attempt  to  rise  or  turn  also 
gives  pain;  pulse  148,  with  a vigorous  stroke.  She  was  bled  eighteen 
ounces  from  a large  orifice,  when  faintness  came  on,  and  the  arm  was  bound 
up.  In  a few  minutes  after  the  bleeding,  the  pulse  was  112,  but  it  soon  rose 
again  to  152.  Although  the  bowels  had  been  moved  so  often,  I thought 
their  flatulent  state  indicated  an  arrest  of  the  peristaltic  movement  from  in- 
flammation of  their  peritoneal  coat;  and,  to  re-excite  them,  she  took  a com- 
mon enema,  which  operated  twice  with  relief.  A flannel  bag,  filled  with 
wheat  bran  soaked  in  boiling  vinegar  and  water,  after  being  well  pressed, 
was  laid  warm  on  the  belly  : it  was  changed  occasionally. 

At  20  minutes  past  3,  p.  m.  The  pulse  145,  with  a smart  stroke;  the 
tenderness  of  the  belly  neither  less  nor  greater.  I took  twelve  ounces  of 


682 


PUERPERAL  FEVER. 


blood  from  the  arm,  in  a large  stream.  I was  obliged  to  stop,  on  account  of 
faintness,  though  I had  first  drawn  the  pillows  from  under  the  head,  in  hopes 
of  getting  a larger  quantity.  In  fifteen  minutes  afterwards,  pulse  144. 

At  4£  p.  m.  Calomel,  gr.  viij .;  Opium,  gr.  iss.  The  powder  was  taken 
for  a dose.  To  drink  gum  water. 

At  6|  p.  m.  Has  slept,  and  feels  decidedly  less  pain  and  soreness ; but, 
as  the  pulse  is  frequent  and  strong,  I took  twenty-two  fluid  ounces  of  blood, 
which  was  carefully  measured.  It  made  a firm  clot,  and  had  a thick  coat  of 
size.  She  took  Manna,  ^ss.;  Sem.  anise,  3b;  Magnes.  carb.  ^ss.;  Aq.  bulli- 
ent.  ^vi.  An  infusion  was  made  of  the  anise  and  manna  in  the  boiling  water; 
which,  when  cool,  was  strained : after  which,  the  magnesia  was  added,  to 
make  a proper  mixture.  A fluid  ounce  was  taken  for  a dose  every  hour, 
until  the  bowels  were  moved. 

At  10§  p.  m.  Pulse  136,  full  and  strong;  the  right  mamma  filling  and 
hardening,  the  left  soft  and  flaccid,  but  the  gland  is  developing  favourably ; 
no  headache ; thirst ; the  soreness  and  pain,  on  pressure,  (carefully  exa- 
mined,) are  very  much  lessened  ; lochia  free  ; decubitus  still  dorsal. 

Monday , 8 a.  m.  Has  slept  a good  deal;  pulse  130,  and  softer;  no  pain 
except  by  firm  pressure  on  abdomen  ; thirst  lessened ; both  mammae  full 
and  hard. 

3 p.  m.  Pulse  120,  full  and  strong;  no  pain,  not  even  from  pressure; 
tongue  clean  ; had  several  stools  ; not  thirsty. 

9£.  Same. 

Tuesday , 9th  November,  9 a.  m.  Pulse  124,  and  strong;  tongue  some- 
what furred ; plenty  of  milk ; breasts  soft ; no  pain ; bowels  moved  again. 

9 p.  m.  Pulse  111;  sore  nipples. 

Wednesday , 10  a.  m.  Has  been  sitting  up  ? no  pain  ; pulse  126. 

In  a few  days  after  this  last  date,  she  was  perfectly  well. 

This  young  woman  had  a healthy  and  strong  constitution.  In  her  case,  I 
took  away,  between  11  and  6 o’clock  on  the  first  day  of  the  attack,  fifty-two 
ounces  of  blood,  without  which,  I think,  she  must  have  died. 

I have  related  the  above  case  from  my  note-book.  I present  it  as  a fair 
specimen  of  the  mode  of  practice,  in  such  attacks,  which  I have  for  years 
been  in  the  habit  of  pursuing.  I have  treated  cases  in  the  Pennsylvania 
Hospital  and  in  private  houses  upon  the  same  principle;  and  I have  the 
satisfaction  to  say,  that  my  just  expectations  of  success,  founded  on  the 
doctrines  of  Gordon,  have  rarely  been  disappointed. — M.] 

OF  PAINFUL  (EDEMA. 

By  this  title,  or  by  that  of  phlegmasia  alba  dolens , is  understood 
an  acute  and  very  painful  swelling  of  the  inferior  extremities,  which 
sometimes  affects  women  in  the  lying-in.  This  inflammatory  swell- 
ing, which  rarely  involves  both  limbs  at  once,  is  attended  with  fever 


MILK-LEG. 


683 


of  considerable  violence,  which  in  some  instances  takes  on  an  adyna- 
mic or  typhoid  character. 

This  disease,  which  the  earlier  writers  designated  as  milk-leg, 
(d£pot  Iciiteux ,)  or  metastasis  of  milk,  has  been  well  investigated  of 
late  years  only,  and  particularly  by  M.  Velpeau,  in  his  Recherches 
et  observations  sur  la  phlegmasia  alba  doleiis , in  the  Archives 
Generates  de  Medecine,  for  Oct.,  1824. 

Among  the  causes  that  give  rise  to  it,  should  be  comprised  all  those 
circumstances  that  obstruct  the  venous  circulation  of  the  lower  ex- 
tremities, by  causing,  to  a certain  extent,  the  blood  to  coagulate 
within  the  vessels  that  happen  to  be  attacked  with  inflammation; 
thus,  pressure  exerted  upon  the  nerves  and  veins  in  the  pelvis,  the 
traumatic  inflammation  of  labour,  uterine  phlebitis  and  phlebitis  of 
the  veins  of  the  pelvis,  suppurative  inflammation  of  the  symphyses, 
and  also  inflammation  of  the  sciatic  and  obturator  nerves,  are  so 
many  circumstances  under  the  influence  of  which  the  disorder  may 
be  brought  on.  It  should  be  further  observed,  that  even  if  an  in- 
flammation of  the  lymphatics  of  the  limb  be  not  the  cause  of  the  dis- 
order, it  may,  nevertheless,  contribute  to  produce  the  phenomena  that 
constitute  the  malady.  Moreover,  a sudden  chilling  of  the  body, 
following  the  copious  perspiration  that  almost  every  woman  in  labour 
has,  is  one  of  the  commonest  among  the  determining  causes  of  phleg- 
masia dolens. 

The  malady  generally  comes  in  with  a chill,  followed  by  intense 
fever  and  by  sudden  pain  in  the  groin  and  thigh,  which  gradually 
swells  from  above  downwards,  and  mostly  upon  its  inner  and  ante- 
rior surface. 

[I  shall  interrupt  the  paragraph  in  order  to  protest  against  M.  C.’s  ac- 
count of  the  onset  of  the  disorder;  or  rather  to  aver  that  in  the  many  cases 
I have  met  with,  the  swelling  is  in  a great  majority  perceived  first  in  the  calf 
of  the  leg,  which  becomes  painful  and  hard  and  swollen  before  the  woman 
suspects  that  she  has  any  pain  at  the  groin  and  in  the  thigh.  When  I hear 
a lying-in  woman  complain  of  pain  of  the  limb,  my  first  attempt  at  diagnosis 
is  to  compress  the  calf  of  the  leg — and  I feel  always  reassured,  as  to  any 
danger  from  phlebitis,  when  she  permits  such  pressure  to  be  made  without 
complaining  of  it  as  painful. — M.] 

The  limb  soon  becomes  infiltrated  completely,  the  skin  is  white, 
glistening,  tense,  and  exceedingly  sensitive  to  the  touch,  but  the  oede- 
ma is  not  really  serous  and  does  not  pit  upon  pressure,  except  upon 
the  points  that  are  not  painful.  The  disorder,  which  ordinarily  lasts 
from  four  to  seven  weeks,  most  commonly  ends  by  suppuration,  in 
enormous  ulcers,  and  sometimes  in  death. 

The  treatment  consists  in  blood-letting,  both  general  and  topical, 
in  cataplasms,  both  emollient  and  narcotic,  cooling  drinks,  absolute 
diet,  baths,  which  are  most  suitable  after  the  fever  is  broken,  and, 
lastly,  in  the  internal  use  of  antiseptics,  when  any  adynamic  symp- 
toms begin  to  be  exhibited. 

[I  disagree  here,  also,  as  to  the  liability  to  suppuration.  In  the  greater 


684 


MILK-LEG,  NEURITIS,  PHLEGMON. 


portion  of  my  cases,  the  patient  has  effected  resolutive  cure  of  the  inflam- 
mation, and  even  where  the  malady  has  resulted  in  the  death  of  the  patient, 
of  which  I have  witnessed  two  instances  only,  the  suppurations  did  not  ap- 
pear externally,  and  were  confined  to  the  membrane  commune  of  the  veins. 
I differ  with  Mr.  C.  as  to  the  necessity  of  treating  separately  phlebitis 
and  phlegmasia  alba,  since  they  constitute  an  identical  case.  Of  this  no 
person  could  doubt,  I should  suppose,  who  had  read  the  observations  on 
phlebitis  by  Dr.  David  D.  Davis,  late  Professor  of  Midwifery  in  the  Lon- 
don University,  and  those  of  Dr.  Robt.  Lee,  of  London,  in  his  writings  on 
crural  phlebitis,  for  which  see  the  volume  on  puerperal  fever,  published  by 
Hasweli  and  Barrington,  of  this  city. — M.] 


PUERPERAL  NEURITIS. 

This  designation  is  applied  to  the  inflammations  of  the  crural  and 
sub-pubal  nerves,  brought  on  by  pressure  during  labour.  The  dis- 
ease, which  until  lately  was  confounded  with  phlebitis  and  neuralgia, 
is  characterized  by  pain  that  is  highly  exasperated  by  pressing  upon 
the  inflamed  nerve,  which  becomes  red  and  swollen,  and  forms  a 
hard,  uneven  cord.  In  some  of  the  cases  phlegmons  are  formed  over 
the  tractus  of  the  nerve,  which  suppurate,  and  in  other  instances,  the 
neuritis  gives  rise  to  painful  cedema. 

The  treatment  of  this  affection  consists  chiefly  in  topical  bleeding, 
carried  to  a proper  extent,  according  to  circumstances,  and  frequently 
repeated,  according  to  the  violence  and  obstinacy  of  the  pain.  It  is 
well,  in  some  specimens  of  the  malady,  to  make  use  of  general  bleed- 
ing; but  it  is  mainly  by  the  use  of  bathing,  emollient  cataplasms  and 
the  energetic  application  of  antiphlogistics,  that  we  may  hope  to 
subdue  the  extreme  pain,  and  even  completely  to  cure  the  patient. 

OF  PHLEGMONOUS  ABSCESS  IN  LYING-IN  WOMEN. 

It  sometimes  happens  that  the  cellular  tissues  of  the  pelvic  muscles? 
as  well  as  the  articulations  of  the  symphyses,  are  the  seats  of  isolated 
inflammation,  giving  rise  to  abscesses  and  phlegmon,  called  milk- 
boils,  which  appear  in  different  parts  of  the  body  in  lying-in  women 
recently  delivered. 

When  these  abscesses  form  around  the  psoas  and  iliac  muscles, 
purulent  collections  often  follow,  which  may  open  at  the  groin,  in 
the  lumbar  region,  and  even  in  the  texture  of  the  labia  pudendi ; 
when,  on  the  other  hand,  these  collections  find  their  way  into  the  blad- 
der of  urine,  into  the  rectum,  or  into  the  cavity  of  the  womb,  the  acci- 
dent is  so  much  the  more  unfortunate,  as  it  very  often  causes  the 
death  of  the  patient.  It  is,  therefore,  of  the  highest  importance  to 
prevent  and  to  combat,  as  early  as  possible,  the  development  of 
these  inflammatory  symptoms  by  the  prompt  and  energetic  applica- 
tion of  the  antiphlogistic  method  of  treatment,  and  where  we  cannot 
succeed  in  preventing  suppuration,  to  give  speedy  issue  to  the  matter, 
by  opening  the  abscess  conformably  to  the  rules  of  the  art;  that  is  to 


INERTIA  OF  THE  WOMB FLOODING. 


685 


say,  by  means  of  the  bistoury  or  the  caustic,  according  to  the  circum- 
stances of  the  case. 

INERTIA  OF  THE  WOMB,  AND  FLOODING  DEPENDING  THEREON. 

By  inertia  of  the  womb  is  understood  the  diminution  or  cessation, 
more  or  less  entire,  of  the  contractions  of  the  organ,  so  that  it  has  no 
farther  power  to  expel  the  foetus  or  placenta,  or  to  contract  itself  after 
being  freed  from  the  fruits  of  the  conception.  The  disorder  may, 
therefore,  be  met  with  either  during  or  after  labour. 

The  causes  of  inertia  of  the  womb  vary  accordingly  as  the  affec- 
tion occurs  at  the  commencement,  during  the  progress,  or  after  the 
termination  of  a labour.  An  attack  of  uterine  inertia,  that  takes  place 
at  the  onset  of  labour,  generally  depends  upon  weakness  of  the 
patient,  and  is  chiefly  met  with  in  women  of  a lymphatic  tem- 
perament, of  a constitution  debilitated  by  trouble,  or  by  antecedent 
attacks  of  disease,  and  by  haemorrhages  that  may  have  occurred 
during  the  pregnancy.  Sometimes  inertia  is  caused  by  the  excessive 
distension  of  the  womb  in  twin  pregnancy,  and  in  dropsy  of  the 
uterus,  and  in  certain  cases  it  is  produced  by  a vivid  emotion,  such 
as  an  exaggerated  feeling  of  modesty,  and  the  presence  of  an  ac 
coucheur,  or  of  some  other  person  or  persons. 

Inertia  coming  on  during  labour  almost  always  depends  upon 
fatigue  of  the  uterus,  where  contractions  have  been  both  too  vio- 
lent, and  too  frequently  reiterated,  or  too  long  continued.  It  may, 
also,  be  occasioned  by  a premature  rupture  of  the  membranes, 
which,  when  the  waters  are  gone  off',  leaves  the  contractions  much 
less  energetic  and  useful.  Indeed,  an  attack  of  inertia  of  the  womb 
coming  on  after  labour  may  be  caused,  not  only  by  the  circum- 
stances we  have  mentioned,  but  may,  likewise,  result  from  a san- 
guine congestion  of  the  brain,  which  no  longer  receives  any  nervous 
influx. 

Where  the  inertia  of  the  womb  comes  on  early  in  a labour,  the 
uterine  contractions  are  feeble  and  few,  and  the  dilatation  of  the 
cervix  takes  place  very  slowly.  It  often  happens  that,  after  many 
days  of  suffering  and  of  useless  efforts,  the  woman  falls  into  a state 
of  extreme  exhaustion,  her  strength  disappears,  and  the  labour 
comes  to  a full  stop  ; there  is  a complete  cessation  of  the  pains,  and, 
where  the  foetus  is  already  engaged  in  the  pelvis,  it  stops  and  makes 
no  further  progress.  The  pulse  is  now  found  to  be  small,  irregular 
and  scarcely  perceptible,  and  when  we  Touch,  the  neck  of  the  womb 
is  found  to  be  in  a state  of  atony,  of  softness  and  relaxation.  Haemor- 
rhage often  comes  on,  too,  which  renders  the  condition  of  the  patient 
still  more  alarming. 

An  attack  of  inertia,  coming  on  in  the  course  of  a labour  already 
advanced,  exhibits  nearly  the  same  symptoms,  with  tins  difference, 
however,  that  they  have  succeeded  to  contractions,  energetic,  fre- 
quent and  prolonged,  and  to  severe  pains  that  have  now  completely 
ceased,  often  have  grown  weaker  and  weaker,  and  less  and  less  fre- 
quent. In  cases  of  this  kind,  both  the  mother  and  the  child  are  in 


686 


INERTIA — FLOODING. 


the  greatest  danger  of  being  lost,  unless  succoured  both  promptly 
and  wisely. 

In  the  form  of  inertia  that  comes  on  after  the  termination  of  the 
labour,  the  womb  fails  to  contract,  and  does  not  exhibit  that  hard, 
spherical  globe  which  we  find  in  the  hypogaster,  when  the  womb 
contracts  naturally.  The  os  uteri  being  in  a state  of  complete 
inertia,  remains  open,  and  the  patient  feels  no  after-pains  from  the 
contractions  of  the  womb — which,  under  such  circumstances,  becomes 
inverted  under  the  slightest  provocation  thereto  by  tractions  made 
upon  the  cord.  This  state  of  affairs  almost  always  brings  on  serious 
haemorrhage.  The  blood  escapes  in  torrents  from  the  genitals,  or  it 
is  retained  within  the  cavity  of  the  womb,  which  constantly  enlarges 
more  and  more  under  the  influx.  In  either  case  the  countenance  of 
the  patient  assumes  a cadaverous  pallor;  the  pulse  grows  weak ; she 
has  tinnitus  aurium,  flushings,  and  very  soon  faints  away.  In  fact,  a 
rapid,  inevitable  death  follows  this  haemorrhage,  provided  there  be 
the  least  delay  in  applying  the  proper  remedies.  If  the  woman  dies, 
the  parietes  of  the  uterus  are  found  thin  and  collapsed  together ; 
indeed,  the  inertia  is  dangerous  in  proportion  to  the  violence  of  the 
haemorrhage  with  which  it  is  complicated. 

The  treatment  of  this  sort  of  paralysis  of  the  womb  varies  ac- 
cordingly as  it  is  simple  or  complicated  with  flooding,  and,  likewise, 
according  to  its  dependence  upon  some  general  debility  in  the 
patient.  -Under  circumstances  such  as  those  last  alluded  to,  particu- 
larly where  hemorrhage  comes  on,  we  should  first  endeavour  to 
improve  the  strength  of  the  female,  by  a few  spoonfuls  of  Madeira 
or  Frontignan,  or  a cordial  draught  with  mint  or  canella  waters, 
with  a few  grains  of  sulphate  of  quinine,  and  a few  drops  of  tincture 
of  saffron  or  mug  wort,  which  exert  a more  special  power  over  the 
womb.  Prof.  Lobstein,  of  Strasburg,  was  in  the  habit  of  prescribing 
borax  with  advantage ; he  gave  a few  grains  for  the  dose.  But 
should  the  labour,  notwithstanding  these  attempts,  prove  to  be  lan- 
guid and  slow,  and  especially  should  the  strength  of  the  patient 
become  more  and  more  exhausted,  the  delivery  should  be  accele- 
rated, either  by  means  of  the  ergot,  of  which  ten  grains  may  be 
given  every  ten  minutes,  in  a glass  of  sweetened  water  ; by  turning 
and  delivering  by  the  feet;  or,  lastly,  by  the  forceps,  where  the  head 
has  already  become  engaged  in  the  pelvis. 

In  case  the  inertia  should  be  complicated  with  uterine  haemor- 
rhage, it  is  our  duty  to  act  still  more  promptly  in  the  way  just 
pointed  out ; and  where  the  flooding  does  not  attack  until  after  the 
birth  of  the  child,  and  before  the  delivery  of  the  placenta,  our  first 
indication  is  to  hasten  the  expulsion  of  the  placenta,  by  pulling  it 
downwards  by  the  umbilical  cord,  with  proper  care,  by  exhibiting  a 
dose  of  ergot,  and  especially  by  carrying  a hand  into  the  womb  to 
take  it  way.- 

Where  the  haemorrhage  persists  after  the  discharge  of  the  after- 
birth, we  should  make  haste  to  apply  cloths  wrung  out  of  a mix- 
ture of  cold  water  and  vinegar  to  the  lower  belly  and  upper  part  of 
the  thighs ; and  at  the  same  time  inject  a similar  mixture  into  the 


FLOODING  FROM  INERTIA MILIARY  ERUPTION.  687 

womb  itself,  or  pass  a hand  np  into  the  uterine  cavity,  with  a view 
to  excite  its  contractile  power.  The  spurred  rye  is  one  of  the  most 
uniformly  successful  agents  in  cases  of  this  kind.  In  all  cases,  before 
we  proceed  to  any  action  whatever,  we  should  satisfy  ourselves  that 
the  womb  is  not  inverted.  In  case  we  should  find  it  inverted,  the 
first  indication  would  always  be  to  reposit  the  organ,  and  recur  to 
the  modes  of  treatment  just  now  pointed  out,  should  the  haemor- 
rhage continue  after  the  restoration  of  the  organ  to  its  natural  posi- 
tion. With  a view  to  sustain  the  womb,  by  means  of  an  internal 
mode  of  compression,  a bladder,  to  be  afterwards  inflated,  might  be 
introduced  into  the  cavity,  while  pressure  is  made  with  a hand  upon 
the  exterior  through  the  integuments  of  the  abdomen,  according  to 
the  plan  proposed  by  M.  Rouget.*  In  fine,  transfusion  of  blood, 
taken  from  another  person,  into  one  of  the  veins  of  the  patient’s 
arm,  is  to  be  looked  upon  as  one  of  those  last  resources  to  which 
we  might  turn  in  the  most  desperate  cases,  as  a means  of  remedy- 
ing the  extreme  debility  consequent  upon  flooding. 

OF  MILIARY  ERUPTION. 

Lying-in  women  are  subject  to  a miliary  eruption,  which  takes 
place  without  any  fever.  This  disorder,  which  is  announced  by 
pricking  sensations  and  itching,  comes  on  during  abundant  perspira- 
tion, whether  spontaneous  or  provoked,  and  exerts  itself  chiefly  on 
the  neck,  breast,  abdomen  and  wrists.  It  is  characterized  by  white 
pimples,  that  are  followed  by  transparent  vesicles  filled  with  colour- 
less serous  fluid.  Yet  it  sometimes  happens,  that  the  vesicles  are  sur- 
rounded with  a reddish  areola  more  or  less  deeply  tinted.  The  disor- 
der, which  commonly  lasts  from  four  to  six  days,  in  most  instances 
goes  off  by  degrees ; but  in  some  of  the  examples,  by  a slight  desqua- 
mation of  the  cuticle.  However,  it  may  be  a complicated  disorder, 
as,  for  example,  with  mucous  inflammations,  such  as  bronchial 
catarrh,  angina,  gastritis,  &c. 

Where  the  malady  exists  without  any  complication,  we  should 
confine  ourselves  to  guarding  the  patient  from  cold  air,  and  to  the 
prescription  of  demulcent  drinks,  and  an  antiphlogistic  regimen. 
Where  the  heat  or  itching,  or  sensation  of  heat,  prove  troublesome, 
relief  may  be  obtained  from  tepid  baths.  Lastly,  where  the  erup- 
tion is  complicated,  we  must  act  according  to  the  requirements  of 
the  concomitant  disorder ; that  is  to  say,  recur  to  demulcent  and 
diluent  drinks,  to  blood-letting,  and  all  the  antiphlogistic  measures 
calculated  to  combat  the  various  phlegmasias,  and,  on  the  other 
hand,  employment  is  demanded  of  the  cinchona,  of  tonics,  and  seda- 
tives or  excitants  in  cases  where  the  eruption  is  complicated  with 
adynamic  or  ataxic  fever. 


Melanges  de  M6d.  et  de  Chirurgie.  Paris,  1810. 


6SS 


AGALACTIA. 


LESIONS  RELATIVE  TO  LACTATION. 

When  the  milk-fever  is  passed,  the  breasts  have  become  to  the 
greatest  degree  distended,  and  the  secretion  of  milk  goes  on  con- 
stantly, as  is  proved  by  the  slow  and  gradual  swelling  of  the  mam- 
mas, in  the  intervals  between  the  giving  of  suck  to  the  child. 

The  quantity  of  milk  secreted  varies  very  much,  for  there  are 
some  women  who  cannot  support  one  child  at  the  breast,  while 
others  can  nurse  several ; in  certain  cases,  there  is  even  an  exube- 
rance of  the  secretion,  which  constitutes  what  is  called  galactir- 
rhcea ; in  other  instances,  on  the  contrary,  the  secretion  fails  either 
wholly  or  in  part,  a state  which  has  received  the  appellation  aga- 
lactia. In  some  women,  the  milk  is  retained  within  the  breasts; 
in  others,  it  flows  involuntarily:  in  some,  it  is  so  thin,  and  so  little 
consistent,  that  it  cannot  suffice  to  sustain  the  child  : and,  lastly,  the 
milk  is  liable  to  modifications  of  colour,  consistence  and  savour  that 
render  it  more  or  less  unfit  for  the  purposes  of  nutrition.  We 
shall  proceed  to  speak  of  the  different  anomalies  of  the  milk  in  suc- 
cession. 

A case  of  agalactia  is  one  in  which  the  mammary  gland  either 
secretes  none,  or  very  little  milk.  In  the  former  case,  it  is  said  to  be 
total ; in  the  latter,  partial.  This  fault  may  be  either  primary,  or 
merely  accidental,  according  as  whether  the  secretion  does  not  come 
on  after  the  birth  of  the  child,  or  whether  the  secretion  becomes  sup- 
pressed or  lessened  by  the  influence  of  some  accidental  cause.  The 
causes  that  may  produce  agalactia  are,  atrophy  of  the  mammary 
gland  ; its  being  either  very  little  or  very  much  developed  ; its  want 
of  vital  energy,  and  all  its  organic  diseases.  Among  the  causes  of 
agalactia  are  alike  arranged  a nervous  temperament ; an  extreme 
degree  of  emaciation,  or  its  opposite;  a state  of  debility  and  languor 
of  the  ordinary  kind,  or  one  produced  by  starvation ; a long  pro- 
tracted disease,  a painful  pregnancy,  profuse  haemorrhages  or  other 
evacuations ; bad  digestion,  leucorrhoea,  abuse  of  venery,  phthisis, 
grief,  and  the  depressing  passions  of  the  mind ; and  the  too  early  or 
too  advanced  age  of  the  patient.  Lastly,  the  application  of  topical 
astringents  or  narcotics  to  the  breasts,  acute  diseases,  gestation,  and 
menstruation,  occurring  during  the  lactation,  are  likewise  causes  that 
may  lessen  or  completely  suppress  the  secretions  of  the  mammary 
glands. 

Though  it  be  always  easy  to  establish  the  diagnosis  of  agalactia, 
upon  the  sole  indication  of  the  patient  herself,  it  is  not  so  always 
with  mercenary  nurses,  who  have  some  interest  in  concealing  the 
truth.  The  want  of  the  milk  secretion  may  always  be  verified  by 
the  following  characters : the  breasts  do  not  swell  and  become  hard 
during  the  intervals  of  giving  suck;  the  child  is  always  hungry, 
even  when  he  has  just  been  nursed ; it  often  asks  for  the  breast,  lets 
it  go,  and  cries  as  soon  as  he  has  taken  hold ; his  urine  is  scanty  and 
infrequent,  he  sleeps  but  little,  grows  thinner,  and  soon  wastes  away. 

Notwithstanding  that  a case  of  agalactia  is  beyond  the  power  and 
resources  of  our  art  in  many  instances,  there  are  some  instances  in 


polygalactia;  milk-consumption. 


689 


which  we  determine,  augment,  and  sustain  the  secretion  of  milk : 
thus  in  pregnant  women  who  are  weak  and  emaciated  to  such  a 
degree  as  to  give  reason  for  fear  lest  no  milk  should  be  formed,  the 
difficulty  may,  in  many  instances,  be  prevented  by  means  of  a tonic 
and  nutritious  diet,  and  by  frictions  on  the  breasts  with  flannel, 
either  dry  or  saturated  with  aromatic  substances.  At  the  same 
time,  we  ought  to  endeavour  to  remove  those  causes  we  have  men- 
tioned, and  to  cure  the  diseases  with  which  the  woman  may  happen 
to  be  attacked.  The  sucking  of  the  child,  and  the  frictions  we  have 
pointed  out,  have  often  proved  sufficient  to  establish  the  secretion, 
by  exciting  the  mammary  gland;  but  where  this  cannot  be  effected, 
the  woman  ought  certainly  to  abstain  from  nursing  her  child.  The 
use  of  what  have  been  denominated  galacto-poietic  substances  has 
fallen  into  disuse,  with  the  exception,  perhaps,  of  the  anise,  the  fen- 
nel and  lentils,  which,  in  some  women,  seem  to  increase  the  milk- 
secretion;  but  it  is  proper  to  observe,  that  in  most  women  these  articles 
are  quite  inefficacious. 

While  agalactia  is  more  promptly  injurious  to  the  child  than  to  its 
mother,  she  may  likewise,  having  lost  her  milk,  be  attacked  with 
a kind  of  hectic,  attended  with  a dry  cough,  and  a sense  of  heat  in 
the  chest,  which  bring  on  rapid  emaciation,  if  the  woman  does  not 
wean  as  soon  as  these  symptoms  become  manifest.  Let  us  add,  that 
the  secretion  may  be  either  lessened,  suspended,  or  completely  dried 
up,  from  the  effects  of  violent  grief,  fright  or  anger.  Very  young 
women,  under  eighteen  years  of  age,  or  those  who  are  too  old,  above 
forty,  give  milk  that  is  not  so  good,  and  in  smaller  quantity,  than 
others.  The  secretion,  also,  is  generally  less  plentiful  after  a first 
than  after  the  subsequent  confinements.  But  there  are  some  women 
who  have  less  and  less  milk  after  each  consecutive  lying-in,  and  who 
at  last  have  none  at  all  for  the  second  or  third  child,  as  if  the  mam- 
mary gland  became  exhausted  by  the  repetition  of  its  action,  instead 
of  becoming  stronger  and  stouter  by  the  exercise  of  its  powers,  as 
generally  happens  with  other  organs.  This  is  particularly  apt  to  be 
the  case  in  women  who  have  very  small  breasts. 

POLYGALACTIA,  AND  MILK-CONSUMPTION. 

Under  these  terms,  and  under  that  of  galactirrhoea,  is  designated 
a too  abundant  secretion  of  milk,  which,  however,  does  not  con- 
stitute a morbid  condition,  unless  the  discharge  of  the  liquid  affects 
the  woman’s  health.  This  exuberance  of  the  milk  is  generally  ac- 
companied by  insomnia,  pains  of  the  back  and  loins,  and  lassitude 
in  the  lower  limbs;  the  milk  becomes  limpid,  and  without  any  con- 
sistence ; the  child  profits  but  little  by  its  nursing,  throws  off  what  it 
takes,  digests  it  badly,  and  grows  thinner  and  thinner. 

A galactirrhoea,  which  mostly  is  merely  an  inconvenience,  and  not 
a disease,  and  which  may  be  caused  by  too  succulent  a diet,  by 
too  frequent  application  of  the  child  to  the  breast,  or  by  irritation  of 
the  nipple,  in  general  requires,  as  to  the  treatment,  nothing  more 
than  exercise,  a vegetable  diet,  the  use  of  pure  water,  a less  fre- 
44 


690 


POLYGALACTIA. 


quently-repeated  application  of  the  child  to  the  breast,  and  some 
slight  revulsion  to  the  skin,  the  mucous  membranes  of  the  digestive 
system  or  the  urinary  organs,  by  means  of  some  sudorific  doses, 
small  saline  doses,  Veiss’  whey  and  diuretic  drinks. 

Though  galactirrhoea  generally  affects  the  health  of  females  but 
slightly,  it  may,  in  some  cases,  give  rise  to  the  symptoms  of  milk - 
phthisis , which  is  preceded  by  loss  of  appetite  or  by  constant  desire 
for  food,  by  a burning  sensation  in  the  pharynx  and  stomach,  and 
by  pain  in  the  chest,  and,  lastly,  by  emaciation  and  loss  of  strength, 
from  which  more  or  less  speedily  death  may  result.  This  disease, 
which  has  been  designated  also  by  the  title  of  nurse's  phthisis , 
( tabes  nutricum,)  and  which  Morton  has  described  so  well,  some- 
times appears  in  women  who  continue  to  nurse  too  long,  or  who 
persist  in  suckling  when  their  constitution  is  unfit  for  it. 

The  treatment  of  this  kind  of  phthisis  demands,  above  all,  that 
the  child  should  be  weaned,  after  which  the  health  is  soon  established 
if  we  resort  to  the  employment  of  food  of  easy  digestion,  and  pro- 
portioned to  the  powers  of  the  stomach ; to  moderate  exercise,  ac- 
companied by  agreeable  means  of  distraction : a milk  diet,  a tisan  of 
Iceland  moss;  rhubarb  in  small  doses;  effervescing  mineral  waters, 
acidulated:  blisters  to  the  interior  of  the  thighs,  and  cups  to  the 
back,  are  likewise  very  useful  in  some  cases;  at  the  same  time, 
good  effects  are  obtained  from  the  internal  and  external  use  of  seda- 
tives, from  syrup  of  white  poppies,  or  from  that  of  lactucarium.  M. 
Rauque  recommends  the  following  liniment  : 

R. — Cherry  laurel  water,  two  ounces;  extract  of  belladonna,  two  scruples;  ether, 
an  ounce. 

We  might,  moreover,  prescribe  frictions  of  the  mammae  with  cam- 
phorated oil  of  chamomile,  or  opodeldoc ; vapour  baths,  with  addi- 
tion of  juniper  berries,  gum  benzoin,  and  other  aromatic  substances. 

Involuntary  discharge  of  the  milk,  which  is  due  to  atony  or  ex- 
cessive sensibility  of  the  nipple,  requires,  in  the  former  case,  exter- 
nal and  internal  excitants,  and,  in  the  latter,  sedatives.  We  should, 
at  the  same  time,  resort  to  astringent  applications  to  the  nipple,  and 
to  a tonic  regimen.  M.  Nauche  speaks  of  having  recommended, 
with  good  effects,  a weak  decoction  of  rhatany,  to  overcome  invo- 
luntary flow  of  the  milk. 

Retention  of  milk  in  the  breasts.  In  some  women  it  happens 
that  there  is  excessive  secretion  of  milk,  without  the  excretion  of  the 
liquid  being  thereby  augmented.  When  this  is  the  case,  the  breasts 
are  distended,  painful,  and  contain  indurated  points,  arranged  in  lines 
which  extend  even  to  the  arm-pits,  and  give  rise  to  a true  inflamma- 
tory engorgement,  if  means  are  not  taken  to  prevent  it.  In  this  con- 
dition, the  first  indication  is  to  have  the  breasts  emptied  by  a vigorous 
child  or  by  an  adult,  or  else  by  a young  puppy,  whose  feet  should  be 
wrapped  in  linen  before  he  is  applied  to  the  breast ; or,  lastly,  by 
means  of  breast-pumps.  Care  must  be  taken  to  keep  the  breasts 
warm,  at  the  same  time  that  we  endeavour  to  diminish  the  secretion 
of  milk,  by  restricting  the  patient  to  a moderately  close  diet,  of  sub- 


POLYGALACTIA. 


691 


stances  not  containing  a great  deal  of  nutriment,  and  by  insisting 
upon  nearly  absolute  rest,  and  especially  upon  inaction  of  the  upper 
extremities.  We  should  endeavour,  moreover,  to  encourage  perspi- 
ration and  the  urinary  secretion,  by  means  of  weak  diaphoretic  and 
diuretic  substances ; as,  for  instance,  decoction  of  the  root  of  the 
Arundo  donax,  with  the  addition  of  ten  or  twelve  grains  of  nitrate 
of  potash,  or  an  infusion  of  borage  or  tilia-flowers,  with  a few  drops 
of  the  spiritus  Mindereri.  It  would  be  well,  at  the  same  time,  to  act 
upon  the  digestive  canal,  by  prescribing  an  ounce  of  phosphate  of 
soda  or  sulphate  of  potassa,  for  which  might  be  substituted  Weiss’s 
whey.  Should  there  be  inflammation  or  spasm  of  the  breasts,  they 
might  be  relieved  by  means  of  emollient  or  narcotic  poultices.  In 
case  the  child  should  be  too  weak  to  nurs.e  freely,  another  nurse, 
whose  milk  flows  more  easily,  ought  to  be  chosen.  Lastly,  if  the 
female  prove  to  be  entirely  incapable  of  suckling,  she  should  be  sub- 
jected to  more  rigorous  diet,  and  some  mild  purgatives  ought  to  be 
prescribed. 

We  shall  add,  moreover,  that  retention  of  the  milk  is  incurable 
when  it  depends  upon  vicious  conformation  of  the  nipple,  such  as  its 
absence  and  its  congenital  or  accidental  imperforation.  If  this  ano- 
maly exists  in  both  breasts  at  the  same  time,  the  woman  ought 
always  to  give  up  the  attempt  to  nurse  the  child.  The  obstruction 
of  the  galactophorous  ducts  is  sometimes  the  result  of  flattening  or 
induration  of  the  nipple ; in  other  cases,  it  may  depend  upon  turge- 
scence  of  the  mammas ; it  often  coincides,  moreover,  with  depression 
of  the  nipples,  which  may  generally  be  remedied. 

Alterations  of  the  milk.  Under  the  influence  of  certain  circum- 
stances, the  milk  is  subject  to  different  alterations  in  its  colour,  con- 
sistence and  taste.  For  example,  after  nervous  diseases,  it  becomes 
thin,  like  water,  or  of  a greenish  colour.  It  assumes  a yellowish 
colour,  in  inflammations  of  the  mammae,  a saltish  and  disagreeable 
taste  in  inflammatory  diseases,  and,  lastly,  a sour  smell,  after  labour 
particularly.  It  contracts  an  odour  like  that  of  garlic  in  persons  who 
eat  that  substance,  a reddish  colour  in  those  who  make  use  of  mad- 
der, and,  lastly,  a bluish  colour  in  women  who  work  in  indigo  manu- 
factures. To  discover  whether  the  consistence  of  the  milk  is  too  thin, 
or  too  thick,  it  is  necessary  merely  to  put  a drop  on  one  of  the  nails. 
If  it  adheres  to  it  at  first,  and  then  spreads  without  running,  it  is  in 
the  natural  condition  ; in  the  contrary  case,  it  is  not  sufficiently  con- 
sistent ; while  it  is  too  thick,  if  the  drop  adheres  to  the  nail  without 
spreading.  This  happens  generally  in  women  who  have  too  much 
embonpoint.  In  nervous  women,  the  milk  is  thin,  not  very  nutri- 
tious, and  subject  to  slight  alterations  after  the  slightest  vexation. 
To  conclude,  very  young  and  very  aged  women  have  milk,  of  quality 
inferior  to  that  of  middle-aged  persons. 

Menstruation  during  lactation  renders  the  milk  thin  and  serous. 
Pregnancy  renders  it  thick  and  unfit  for  the  nourishment  of  children. 
Different  kinds  of  food,  amongst  others  salt  meats,  highly-seasoned 
dishes,  mealy  vegetables,  salad  and  fruits,  make  the  milk  more  abun- 
dant, but  thinner ; spirituous  drinks,  late  hours,  excessive  sleep,  and 


692 


DISEASES  OF  THE  BREAST. 


all  abundant  excretions,  diminish,  on  the  contrary,  the  quantity  of 
the  fluid,  the  least  alteration  of  which  may  have  an  unfavourable 
effect  upon  the  child.  It  is,  therefore,  of  the  highest  importance,  on 
account  of  the  latter,  as  soon  as  possible,  to  remove  these  faults, 
which  destroy  a large  number  of  children  in  ail  classes  of  society. 

The  treatment  of  the  different  alterations  ought  to  consist  simply 
in  the  removal  of  the  causes  which  have  produced  them,  either  by 
changing  the  diet  of  the  nurse,  or  by  curing  the  affections  of  the 
mammae  or  the  other  diseases  which  give  rise  to  them,  or  else  by 
changing  the  nurse  or  by  weaning  the  child  when  of  suitable  age. 

DISEASES  OF  THE  MAMMJ3. 

It.  sometimes  happens,  especially  in  a first  lactation,  that  the  nipple 
becomes  the  seat  of  excoriations  and  fissures  that  are  generally  ex- 
tremely painful.  This  condition  may  be  produced  by  the  too  fre- 
quent or  violent  sucking  which  the  infant  is  forced  to  use,  principally 
where  the  nipple  is  badly  shaped,  or,  if  the  organ  is  in  the  normal 
state,  by  the  acrid  character  of  the  saliva  of  the  child,  and  by  the 
force  with  which  it  draws. 

This  state  of  phlogosis  of  the  nipple  may  often  be  prevented  by 
keeping  it  clean  and  avoiding  any  exposure  of  it  to  the  air  and  to 
the  contact  of  the  clothes,  and  especially  of  the  corsets.  If  it  has 
been  impossible,  in  spite  of  these  precautions,  to  prevent  the  deve- 
lopment of  the  inflammation,  it  should  be  treated  by  means  of  emol- 
lient fomentations  or  poultices.  When  ulcerated  cracks  or  fissures, 
which  generally  give  rise  to  intolerable  pain  during  suckling,  make 
their  appearance,  we  must  combine,  with  the  means  we  have  pro- 
posed, frictions  of  cerate  containing  opium,  and  not  permit  the  child 
to  nurse  until  the  nipples  have  been  covered  with  shields  made  of 
caoutchouc,  softened  by  plunging  them  into  boiling  water  for  a few 
minutes,  and  which  should  be  sweetened  with  a little  honey,  after 
they  are  applied,  in  order  to  tempt  the  child  to  seize  them. 

Should  the  ulcerations  oi\the  nipples  be  of  venereal  character,  that 
is  to  say,  forming  an  ulcer  \^ith  irregular,  perpendicular  edges,  dis- 
charging an  acrid,  ichorous  matter,  and  especially  if  me  female  pre- 
sent other  syphilitic  symptoms,  recourse  must  be  had  to  a general 
anti-venereal  treatment,  and,  for  the  dressings,  an  equal  portion  of 
strong  mercurial  ointment  might  be  added  to  the  cerate,  containing 
opium. 

To  conclude,  depression  or  imperfect  development  of  the  nipple 
may  be  remedied,  by  having  the  breasts  gently  drawn,  for  some  time 
before  delivery,  either  by  the  woman  herself,  with  the  aid  of  a pipe, 
or  by  some  other  person.  This  result  is  attained  still  better  by  apply- 
ing over  each  nipple  the  mouth  of  a phial  previously  warmed,  and 
the  mouth  being  wide  and  well  rounded  off.  The  application  of 
this  species  of  cup  generally  elongates  the  nipple  and  solicits  the 
escape  of  a greater  or  less  quantity  of  milk.  The  operation  should 
be  repeated  two  or  three  times  a day,  and  care  must  be  taken  to 
wash  the  nipple  each  time,  with  sweetened  wine  and  a little  oil  of 


INFLAMMATION  OF  THE  BREAST,  OR  WEED. 


693 


sweet  almonds.  It  is  proper  to  add  that,  in  cases  where  the  nipple, 
after  delivery,  seems  short  and  small,  merely  because  of  the  swelling 
and  tension  of  the  breast,  it  is  necessary  to  suspend  the  lactation, 
and  feed  the  child  with  the  bottle,  until  the  tumefaction  has  sub- 
sided to  such  a degree  as  to  render  the  lactation  practicable. 


OF  INFLAMMATION  OF  THE  MAMMJE,  OR  THE  WEED. 

Inflammation  of  the  breast  is  generally  developed  in  lying-in 
women,  or  in  those  who  have  been  recently  delivered,  and  sometimes 
during  lactation,  or  at  the  period  of  weaning.  The  affection,  vulgarly 
denominated  weed , may  be  the  result  either  of  engorgement  of  milk, 
the  excretion  of  which  occurs  with  difficulty,  of  the  action  of  cold  or 
excessive  heat,  of  compression  of  the  glands,  of  astringent  applica- 
tions, or  violence  done  to  the  organs,  or,  again,  of  the  acute  pain  and 
irritation  which  some  women  experience  when  the  child  seizes  the 
nipple.  The  disease  makes  its  appearance  generally  on  the  fourth  or 
fifth  day  after  delivery,  and  principally  affects  persons  who  do  not 
wish  to  nurse,  those  who  have  a great  flow  of  milk  and  suckle  a 
feeble  child,  or  who  wean  suddenly,  or,  lastly,  those  who  have  the 
nipples  either  too  little  or  too  large.  Generally,  the  engorgement  is 
seated  in  only  one  breast;  but,  in  some  cases,  both  are  diseased  at 
the  same  time,  and  sometimes  the  inflammation  passes  from  one  into 
the  other. 

The  symptoms  of  the  affection,  which  may  also  be  produced  by 
violent  passions  and  any  acute  and  sudden  emotion,  vary  as  the 
engorgement  is  simple  or  complicated  with  inflammation.  In  the 
former  case,  which  is  a milk  congestion,  merely,  the  disease  is  pre- 
ceded by  rigors  in  the  back,  followed  by  heat;  but  the  fever  does 
not  generally  last  more  than  twenty-four  hours,  unless  the  en- 
gorgement pass  into  the  inflammatory  state.  The  breasts,  which 
were  soft  and  even,  become  hard,  and  unequal,  but  preserve  their 
normal  colour.  Nevertheless,  it  sometimes  happens  that  the  dis- 
ordered mamma  becomes  the  seat  of  indurations,  and  the  secretion 
of  milk  is  always  diminished  or  completely  suspended,  while  the 
patient  feels  a more  or  less  painful  sensation,  which  affects  the  whole 
breast,  and,  in  some  cases,  extends  even  to  the  arm-pits. 

In  the  second  condition,  that  is  to  say,  when  the  engorgement 
becomes  inflammatory,  the  mammae,  which  gradually  augment  in 
size,  and  whose  form  varies  according  to  the  seat  of  the  inflam- 
mation, become  very  painful  and  hard ; are  excessively  hot  and 
tense,  and  assume  a reddish  colour ; the  female  experiences,  at  the 
same  time,  lancinating  and  pricking  pains ; fever,  which  is  always 
proportioned  to  the  engorgement,  arises;  the  headache  increases 
more  and  more,  and  is  acute  ; the  face  flushes,  the  urine  diminishes 
in  quantity,  and  deposits  a whitish  sediment;  the  fecal  matters  ex- 
hale an  acid  odour;  lastly,  the  inflamed  breast  acquires  a consider- 
able size  and  tension,  which  extend  even  to  the  arm-pits  and  to  the 
neck;  and  sometimes  the  pains  become  so  acute  that  cerebral  symp- 
toms and  delirium  are  manifested. 


694 


INFLAMMATION  OF  THE  MAMMJE. 


The  simple  and  mild  engorgement  terminates  generally  by  resolu- 
tion, whilst  suppuration  is  the  most  common  termination  of  the  inflam- 
matory and  really  phlegmonous  engorgement.  This  affection,  how- 
ever, which  sometimes  passes  into  the  state  of  induration  and  scirrhus, 
very  often  terminates  by  resolution,  especially  if  the  female  clothes 
herself  warmly,  and  follows  a suitable  treatment.  This  fortunate 
termination  is  preceded  by  rapid  diminution  and  disappearance  of 
the  inflammatory  symptoms,  and  by  gradual  softening  of  the  affected 
gland,  which,  in  some  instances,  is  covered  with  small  drops  of  per- 
spiration. It  is  proper  to  remark,  that  there  often  occur  critical 
evacuations,  amongst  others  sweats,  alvine  dejections,  and  abundant 
and  sedimentary  discharges  of  urine. 

We  ascertain  that  suppuration  is  taking  place  by  the  continuation 
and  progressive  augmentation  of  the  inflammatory  symptoms.  The 
diseased  breast  constantly  increases  in  size,  and  becomes,  throughout, 
the  seat  of  throbbing  pains  and  intolerable  shootings.  The  patient 
has  vague  and  irregular  rigors,  the  skin  becomes  dry,  the  fever 
assumes  a marked  intermittent  character,  with  evening  exacerbation, 
and  sometimes  with  delirium.  At  length  the  existence  of  fluctua- 
tion in  some  portion  of  the  mamma  leaves  no  doubt  as  to  the  forma- 
tion of  a purulent  collection.  We  deem  it  proper  to  add,  that  when 
the  engorgement  terminates  in  induration,  the  progress  of  the  disease 
is  very  slow,  and  the  hardness  augments  by  insensible  degrees. 

The  prognosis  of  the  engorgement  under  consideration  is  not  un- 
favourable in  itself;  but  the  accidents  which  may  accompany  it  are 
often  troublesome,  for  there  may  result  from  it  abscesses,  fistulas  and 
indurations,  which  dispose  to  new  engorgements  in  other  layers. 

The  preventive  treatment  of  the  disease  consists  in  the  early 
application  of  the  child  to  the  breasts,  in  order  to  empty  them  as 
soon  as  they  are  filled;  and  in  removing,  as  far  as  possible,  the  causes 
which  give  rise  to  engorgement.  The  curative  treatment,  in  the  be- 
ginning of  milk  congestion,  consists  in  the  disengorgement  of  the 
breast  by  means  of  natural  or  artificial  suckling,  and  by  abstinence 
from  very  nourishing  food  or  by  rigorous  diet,  while,  at  the  same 
time,  we  endeavour  to  increase  the  flow  of  the  lochia,  or  to  produce 
revulsion  to  the  skin  or  alimentary  canal.  It  is  useful,  also,  to  cover 
the  breast  with  a lamb’s,  a rabbit’s  or  a swan’s  skin,  and  to  anoint  it 
with  a liniment  of  oil  and  liquid  ammonia,  in  proper  proportions, 
especially  when  there  is  little  or  no  pain.  We  might  also  employ  a 
poultice  of  flax-seed  meal  and  water,  containing  soap,  with  the  addi- 
tion of  ten  or  twelve  grains  of  subcarbonate  of  potash  ; and  frictions 
of  oil  and  lime-water,  or  of  two  drachms  of  camphor  dissolved  in  the 
yolk  of  an  egg. 

If  the  engorgement  passes  into  an  inflammatory  condition,  that  is 
to  say,  if  the  breast  becomes  tense  and  extremely  painful,  with  fever, 
heat,  restlessness,  cephalalgia,  etc.,  prompt  recourse  should  be  had  to 
bleeding  from  the  arm,  then  to  the  application  of  leeches  upon  the 
breast,  to  the  use  of  emollient  and  narcotic  poultices,  to  rigorous  diet, 
to  sedative  drinks,  to  rest  in  the  horizontal  position,  to  the  employ- 
ment of  fumigations  to  the  seat  of  the  disorder,  and,  lastly,  to  that  of 


INFLAMMATION  OF  THE  MAMMiE, 


695 


antispasmodics  and  sedatives,  where  the  pains  are  very  acute,  and 
especially  if  the  female  be  nervous.  In  case  the  disease  should  have 
appeared  after  a suppression  of  the  lochia,  the  means  proper  to 
recall  the  discharge  ought  to  be  employed ; cups  should  be  applied 
to  the  groins,  loins  and  thighs,  and  calomel  in  small  doses,  or  some 
other  mild  purgatives,  must  be  administered.  It  is  proper  to  remark, 
that  the  female  ought  not  to  suckle  with  the  diseased  breast,  until  it 
has  been  somewhat  disengorged. 

If  the  engorgement,  inclining  towards  resolution,  diminishes,  soft- 
ens and  becomes  less  painful,  we  should  resort  to  emollient  poultices, 
sprinkled  with  a few  drops  of  solution  of  acetate  of  lead,  or  red  wine, 
or  with  a solution  of  muriate  of  soda  or  carbonate  of  potash.  We 
might  also  employ,  towards  the  close  of  the  inflammation,  the  pulp 
of  the  hemlock,  chervil  or  parsley,  applied  very  warm  to  the  breasts. 
Liniments  composed  of  a solution  of  carbonate  of  potash,  of  muriate 
of  ammonia,  or  of  soap  in  equal  parts  of  water  or  milk,  have  also 
been  used  with  advantage  in  these  cases.  Moreover,  the  effect  of 
these  means  ought  to  be  seconded  by  mild  purgatives,  by  suitable 
regimen,  and  by  careful  movements  of  the  arms,  so  as  to  bring  the 
pectoral  muscles  into  action,  and  thus  hasten  the  resolution. 

To  conclude,  when  the  engorgement  passes  into  the  state  of  sup- 
puration, we  ought  to  insist  upon  emollient  topical  applications,  to  pro- 
mote the  formation  of  pus,  which  may  be  much  assisted  by  means  of 
poultices  of  sorrel  and  hog’s  lard,  or  of  lily-roots  roasted  in  the  ashes. 
When  the  purulent  collection  is  fully  formed  and  fluctuation  distinct, 
we  ought,  if  the  abscess  is  small,  to  allow  it  to  open  of  itself;  but  if 
the  collection  is  extensive,  and  especially  if  the  mammary  gland  is 
less  affected  than  the  cellular  tissue,  which  may  be  known  by  the 
slight  depth  of  the  suppuration,  it  becomes  necessary  to  give  issue  to 
the  pus,  by  means  of  a vertical  incision,  made  with  a narrow  lancet 
or  bistoury,  in  the  most  dependent  part  of  the  tumour;  then,  after 
the  purulent  matter  has  been  evacuated,  a little  plug  of  linen  is  to  be 
introduced  into  the  opening,  to  prevent  it  from  closing  too  soon. 
The  dressing  should  consist  of  a compress  pierced  with  holes,  and  of 
charpie,  and  the  mamma  must  be  enveloped  in  an  emollient  poultice, 
until  the  heat,  pain  and  induration  of  the  tumour  have  disappeared. 
If  the  breast  is  very  large,  it  is  to  be  supported  by  a proper  bandage, 
and  we  should  make  use  of  the  revellents  indicated  above.  If  fistu- 
las, discharging  small  quantities  of  serous  pus,  remain,  and  which 
heal  up  slowly,  the  breast  is  to  be  covered  with  emollient  and  revel- 
lent  poultices,  and  it  must  be  washed  with  soapy  and  alkaline  solu- 
tions, made  gradually  stronger  and  stronger.  It  is  proper  to  remark, 
moreover,  that  the  engorgement  which  terminates  by  induration, 
ought  to  be  treated  by  frictions,  repeated  several  times  daily,  with 
some  volatile  liniment,  and  by  mild  purgatives;  and,  if  the  tumour  is 
entirely  indolent,  by  plasters  of  soap,  of  conium,  or  by  that  of  vigo. 
It  is  always  useful  to  keep  the  breasts  very  warm,  by  covering  them 
with  flannel,  or  with  swan  or  rabbit-skin. 

Our  remarks  upon  the  diseases  peculiar  to  females  are  here  brought 
to  a conclusion.  While  it  appears,  from  the  sad  picture  we  have 


696  HYGIENE  OF  THE  PREGNANT  AND  THE  PARTURIENT. 

drawn,  that  the  different  affections  to  which  they  are  subject  are,  for 
the  most  part,  extremely  dangerous,  it  also  appears  that  it  is  possible, 
in  most  cases,  to  prevent  and  to  cure  them  by  an  early  resort  to 
the  different  prophylactic  and  therapeutical  agents,  of  which  expe- 
rience proves  the  efficacy  and  daily  verifies  the  truth  of  the  old 
adage : 

Principiis  obsta ; sero  medecina  paratur 
Cum  mala  per  longas  invaluere  moras. 

Ovid. — Remedia  Amoris.  Y.  91  and  92. 


HYGIENE  OF  PREGNANT  AND  LYING-IN  WOMEN. 

While  a pure  atmosphere  is  of  the  highest  importance  to  health  at 
all  periods  of  existence,  it  is  during  the  pregnant  state  especially  that 
it  becomes  indispensable.  Hippocrates,  Baillou,  Bartholin,  Stoll, 
Lepecq-de-la-Cloture,  and  several  other  observers,  have  remarked 
the  bad  effects  of  a damp  or  too  dry  an  atmosphere,  upon  pregnant 
women,  and  assert  that  it  predisposes  to  abortions  and  to  premature 
labours.  They  ought,  therefore,  as  far  as  possible,  to  breathe  an 
atmosphere  which  is  pure  and  exempt  from  all  extremes  of  cold  or 
heat,  dryness  or  humidity. 

Their  clothing  should  be  loose,  and  so  arranged  as  to  avoid  all 
pressure  upon  the  breasts,  chest,  abdomen  and  stomach.  Pressure 
upon  these  organs  may  interfere  with  the  growth  of  the  mammae  and 
the  development  of  the  nipples ; it  may  augment  the  embarrassment 
of  the  respiration,  prevent  the  enlargement  of  the  uterus  and  its 
ascent  in  the  abdomen  ; and,  lastly,  become  a cause  of  abortion,  or  of 
displacement  of  the  gestative  organ,  as  has  been  remarked  by  White 
and  Doering.  Pregnant  women  should  especially  avoid  the  use  of 
corsets  with  busks  or  whalebones,  which  are  very  hurtful,  while  the 
pressure  which  they  exert  from  above  downwards  acts  upon  the 
uterus,  forces  it  to  develop  itself  in  a dependent  situation,  and  be- 
comes a powerful  cause  of  prolapsus  uteri,  and,  according  to  some 
authors,  a cause  of  deformity  of  the  foetus,  even.  They  ought  to 
wear,  therefore,  elastic  and  very  large  corsets  only,  for  which  should 
be  substituted,  after  the  fifth  month,  an  equally  elastic  binder, 
which,  embracing  the  abdomen  in  every  direction,  maintains  the 
uterus  in  a normal  position,  and,  as  far  as  possible,  prevents  the 
wrinkles  and  cracks  which  are  generally  the  results  of  pregnancy. 
During  winter,  pregnant  women  ought  to  take  care  to  wear  flannel 
drawers,  in  order  to  escape  the  action  of  the  cold  upon  the  thighs 
and  sexual  organs,  which  are  the  more  exposed  to  it  because  of  the 
prominence  of  the  abdomen,  which  shortens  the  petticoats  and 
pushes  them  forwards.  They  ought  to  endeavour  likewise  to  protect 
the  mammae,  the  shoulders  and  the  superior  extremities,  from  cold. 
Inattention  to  this  precept  has  sometimes  occasioned  very  extensive 
inflammation  of  the  breasts,  followed  by  abscesses,  which  has  not 
generally  been  cured  until  after  the  delivery.  Circular  compression 
of  the  inferior  extremities  is  no  less  dangerous,  especially  towards 
the  latter  months  of  the  gestation,  for,  by  retarding  the  flow  of  the 


BATHING,  BLOOD-LETTING,  ETC. 


697 


fluids,  they  produce  (Edematous  engorgements  and  varicose  dilata- 
tions of  the  inferior  extremities. 

The  use  of  warm  baths,  which  were  always  proscribed  by  the 
ancients,  in  pregnant  women,  is  nevertheless  very  useful.  As  they 
promote  the  cutaneous  perspiration,  relax  the  tissues  and  cleanse  the 
skin,  they  are  suitable  for  primiparous  women,  and  especially  for  those 
of  advanced  age,  whose  soft  parts  are  hard  and  resisting,  and  whose 
uterine  and  abdominal  parietes  are  distended  with  difficulty : they 
are  prescribed  also  for  the  purpose  of  relaxing  the  symphyses  of  the 
pelvis,  of  softening  the  external  parts  of  generation,  of  preventing 
lacerations,  and  to  facilitate  labour.  The  use  of  baths  is  suitable 
also  for  nervous  and  irritable  women,  who  are  very  subject  to  colics 
and  convulsions;  they  are  injurious  in  those  who  have  much  embon- 
point, in  those  of  lymphatic  temperament,  and  who  are  subject  to 
oedema  and  haemorrhages.  Persons  of  the  latter  description  should 
make  use  of  them  only  for  purposes  of  cleanliness,  therefore,  and 
should  remain  in  them  as  short  a time  as  possible.  The  best  time  for 
the  employment  of  baths  is  at  the  commencement  and  at  the  end  of 
the  pregnancy ; about  the  first  month,  in  order  to  allay  the  spasm  and 
excitation  of  the  uterus,  and  in  the  last,  in  order  to  dispose  the  genital 
organs  to  the  distension  which  they  are  about,  to  undergo.  If  we 
prescribe,  or  if  we  consent  to  the  use  of  baths  by  plethoric  women, 
it  will  be  most  prudent  to  precede  their  employment  by  a bleeding 
at  the  arm,  performed  some  days  beforehand.  In  some  cases,  cold 
river-baths  may  be  proper ; but  the  women  ought  to  be  careful  not 
to  expose  the  abdominal  parietes  against  the  current  of  the  water, 
which,  in  that  position,  would  act  like  a douche.  Foot-baths  are 
generally  forbidden ; nevertheless,  they  ought  to  be  allowed  for  the 
purposes  of  cleanliness,  with  the  precaution,  however,  of  keeping 
the  feet  in  the  water  only  so  long  as  is  strictly  necessary  to  cleanse 
them. 

Bleeding,  likewise,  ought  to  be  avoided,  unless  some  accident 
happens,  and  unless  called  for  by  some  particular  indication.  It 
becomes  necessary,  on  the  contrary,  to  recur  to  its  employment  at  all 
periods  of  pregnancy,  in  plethoric  women,  in  whom  the  pulse  is 
strong,  full  and  accelerated,  and  who  suffer  from  insomnia,  from 
excessive  agitation,  from  cephalalgia,  or  from  nasal,  pulmonary  or 
uterine  haemorrhages.  Bleeding  at  the  arm  ought  always  to  be  pre- 
ferred to  bleeding  from  the  foot,  although  the  latter,  in  the  greater 
number  of  cases,  is  not  followed  by  any  accidents. 

The  derangements  of  the  digestive  functions  and  the  state  of  san- 
guine plethora,  which  are  the  general  results  of  pregnancy,  suffix 
ciently  indicate  that  pregnant  women  ought,  especially  during  the 
early  months,  make  use  only  of  light  food,  containing  but  little  nutri- 
tious matter,  of  easy  digestion,  and  selected  chiefly  from  amongst 
the  vegetables.  Nevertheless,  towards  the  middle  of  the  gestation, 
the  period  at  which  the  appetite  reappears  and  the  digestive  functions 
are  generally  re-established,  it  becomes  proper  to  relax  the  severity 
of  the  regimen,  and  allow  of  more  food  at  each  repast ; with  the 
precaution,  however,  of  renewing  the  latter  often  enough  to  sup- 


69S 


DIET,  EVACUATIONS,  EXERCISE. 


ply  sufficient  nourishment,  without  overloading  the  stomach.  The 
custom  of  making  pregnant  women  eat  for  two , as  it  is  vulgarly 
expressed,  is  the  more  pernicious,  because  it  occasions  a super-exci- 
tation of  the  digestive  organs,  which  is  generally  followed  by  more 
or  less  obstinate  vomiting,  colic  or  diarrhoea.  We  must  remark, 
however,  that  the  tastes  and  desires  of  the  patient  should  be  re- 
spected, provided  they  do  not  concern  articles  evidently  injurious. 
Though  it  is  wrong  to  yield  to  all  their  caprices  of  appetite,  it  is  also 
wrong  to  resist  desires  which  often  persist  in  spite  of  them,  and 
which  are  sometimes  the  indications  of  nature  itself.  It  is  proper  to 
remark,  moreover,  that  the  excessive  use  of  warm  drinks  may  be 
hurtful,  by  debilitating  and  relaxing  the  stomach  ; and  that  the  abuse 
of  fermented  drinks,  of  liqueurs,  of  coffee  and  tea,  and  of  irritating 
condiments,  is  equally  pernicious,  by  increasing  the  already  too 
great  excitation  of  pregnant  females,  from  which  may  result  convul- 
sions. uterine  haemorrhages  and  abortions.  The  use  of  iced  drinks, 
which  is  often  one  of  the  best  means  of  allaying  gastralgia  and 
vomiting,  may  also  become  a cause  of  abortion ; examples  of  which 
are  reported  by  Mauriceau  and  other  authors. 

In  some  women,  we  find  disorders  of  the  urinary  secretion  and 
intestinal  excretions.  Emollient  enemata  will  be  useful  to  calm  not 
only  intestinal  and  vesical  irritations,  but  also  to  facilitate  digestion, 
to  prevent  and  overcome  vertigo  and  cerebral  congestions,  and  even 
to  aid,  in  the  primipara,  the  dilatation  of  the  genital  parts,  at  the 
moment  of  delivery.  Nevertheless,  their  habitual  use  should  be  re- 
stricted to  the  well-ascertained  cases  that  require  them ; for  they 
may  lead  to  constipation  and  intestinal  torpor,  and  an  abnormal 
relaxation  of  the  genital  organs.  One  ought  especially  to  be  very 
circumspect  as  to  the  use  of  purgative  injections,  which,  in  conse- 
quence of  the  relations  existing  betwixt  the  rectum  and  the  womb, 
may  bring  on  contractions  of  that  organ,  and  thus  give  rise  to  miscar- 
riage. As  a general  rule,  purgatives  ought  to  be  rejected  upon  the 
same  considerations;  and  the  conduct  of  those  practitioners  who 
prescribe  what  are  called  precautionary  purgatives,  cannot  be  too 
much  condemned.  The  use  of  emetics  ought  likewise  to  be  pro- 
scribed; and  notwithstanding  they  are  often  taken,  without  effect, 
by  women  who  desire  to  make  a criminal  use  of  them,  still  they 
should  never  be  resorted  to  except  in  cases  of  absolute  necessity. 

Exercise,  which  ought  never  to  be  carried  to  the  extent  of  fatigue, 
is  very  useful  for  pregnant  women ; it  maintains  a regular  action 
of  all  the  functions,  prevents  the  attack  of  many  diseases,  and  is 
often  a means  of  cure.  The  most  suitable  mode  of  exercising  for 
such  persons  is  walking,  both  morning  and  evening,  during  the  fine 
weather,  and  at  noon,  during  the  winter.  The  lengih  of  the  walks 
should  be  calculated  agreeably  to  the  state  of  the  strength  and  habits 
of  the  woman  ; yet  there  are  women  who  cannot  go  out  their  full  time 
except  on  the  condition  of  keeping  perfectly  still,  and  in  a horizontal 
posture.  Riding  on  horseback,  or  in  a carriage,  and  dancing,  expose 
her  to  shocks  that  are  the  frequent  causes  of  haemorrhages  and  abor- 
tion. Moreover,  women  in  a state  of  pregnancy  ought  to  enjoy 


VIOLENT  MENTAL  IMPRESSIONS. 


699 


protracted  sleep,  which,  in  that  state,  they  require  more  than  at  any 
other  period  of  their  lives.  We  ought,  therefore,  to  treat  the  case  of 
insomnia  and  agitation  to  which  they  are  liable,  especially  in  the 
last  months  of  pregnancy,  by  baths,  exercise  and  blood-letting,  and 
by  some  gentle  narcotic,  such  as  distilled  lettuce-water  and  orange- 
flower  water,  the  syrup  of  thridace,  or  with  certain  of  the  potions 
into  which  these  articles  enter  as  their  basis,  and  to  which  may  be 
added  some  drops  of  sulphuric  ether.  The  narcotics,  properly  so 
called,  especially  the  opiates,  do  not  succeed  so  well. 

The  exalted  state  of  the  sensibility  in  pregnant  women,  rendering 
their  sensations  more  acute,  and  their  emotions  more  energetic,  they 
ought,  with  equal  care,  to  shun  the . occasions  of  violent  impressions 
upon  the  physical  and  upon  the  moral  constitution ; and  all  objects 
capable  of  affecting  the  imagination  should  be  cautiously  kept  out  of 
their  way;  such  as  tragical  spectacles,  tlie  sight  of  mutilated  people, 
of  the  lame,  and  of  all  persons  affected  with  loathsome  diseases.  As 
they  are,  in  general,  persuaded,  however  erroneously,  that  the  sight 
of  such  an  object  may  give  rise  to  a similar  deformity  in  the  child  in 
utero,  they  are  violently  agitated  whenever  they  meet  with  it.  Be- 
sides, the  records  of  disease  are  full  of  cases  of  serious  disorders, 
as  convulsions,  hsemorrhages  and  abortions,  brought  on  by  the  sight 
of  some  repulsive  object,  by  fright,  by  a paroxysm  of  anger,  a fit  of 
joy,  of  hate,  of  jealousy,  or  other  acute  emotion  of  the  soul.  From 
among  the  numerous  histories  of  this  sort,  we  shall  quote  one  only, 
from  the  writings  of  Sue.  It  is  the  case  of  a woman  who  was  so 
much  affected  by  the  prediction  of  a gipsy,  who  foretold  that  she 
would  die,  that  she  made  her  will,  and  died  in  the  eighth  month.  It 
is  ridiculous  to  believe  in  the  injurious  effects  of  longings  and  desires, 
and  the  prejudices  which  pretend  that  the  woman’s  imagination  may 
exercise  a powerful  influence  upon  her  child,  and  that  when  she  longs 
for  any  thing,  or  is  powerfully  affected  by  any  object,  there  is  esta- 
blished a deformity  resembling  the  object  of  her  fright,  upon  that  part 
of  the  infant’s  body  that  corresponds  to  the  part  of  her  own  surface 
which  she  happens  first  to  touch  with  her  finger,  after  experiencing 
the  sensation.  However,  as  these  various  causes  may  produce  violent 
agitation  in  credulous  females,  and  exert  an  injurious  influence  upon 
the  foetus,  it  is  requisite  to  pay  great  attention  to  the  state  of  her 
mind,  so  that  she  may  be  treated  with  gentleness  and  respect,  and 
especially  with  indulgence  as  to  her  caprices  and  oddities,  which 
are  for  the  most  part  involuntary.  As  abortion  is  often  the  conse- 
quence of  the  voluptuous  and  tumultuous  ecstasies  of  the  venereal 
indulgence  during  pregnancy,  the  conjugal  embrace  ought  to  be  in- 
terdicted during  the  early  months,  particularly  to  newly-married  wo- 
men, and  to  those  who  have  already  been  subject  to  abortion.  In 
case,  however,  of  excessive  desire  in  both  parties,  there  might  be 
more  inconvenience  in  resisting,  than  danger  in  gratifying  it,  with 
moderation.  As,  during  the  last  six  months  of  gestation,  the  danger 
is  much  less  than  in  the  first  three  months,  the  indulgence  of  the 
habit  may  be  enjoyed  with  less  restraint. 


700 


HYGIENE  OF  PARTURIENT  WOMEN. 


HYGIENE  OF  THE  LYING-IN  WOMAN. 

The  term  of  pregnancy  having  arrived,  it  is  important,  as  soon  as 
the  first  signs  of  labour  are  manifest,  to  free  the  woman  from  such 
parts  of  her  dress  as  might  prove  troublesome,  and  to  order  her  to 
take  one  or  two  small  emollient  injections,  with  a view  to  empty 
the  large  intestines  and  the  rectum;  the  matters  of  which,  being  accu- 
mulated in  their  cavities,  might  render  the  labour  more  difficult.  It 
would  be  likewise  useful  to  introduce  the  catheter,  should  the  pres- 
sure exerted  by  the  womb  on  the  neck  of  the  bladder,  hinder  the 
patient  from  discharging  the  urine.  Without  trying  to  prevent  her 
from  crying  out  with  the  pains,  it  is  proper  to  advise  her  to  save  her 
strength  ; while,  under  some  pretext,  we  should  get  rid  of  all  persons 
who  might  tease  her  by  their  mere  presence, — even  her  mother,  her 
sister,  or  husband. 

If,  notwithstanding  the  frequency  and  strength  of  the  pains,  the 
dilatation  of  the  womb  progresses  very  slowly,  the  patient  may  be 
bled,  particularly  if  she  be  of  a strong  constitution,  and  complains  of 
headache  and  a sense  of  heaviness  of  the  limbs.  As  a means  of 
relief  for  the  rigidity  of  the  genital  organs,  recourse  may  be  had  to 
emollient  tepid  fumigations  to  the  parts,  or  to  the  use  of  baths  and 
of  mucilaginous  injections  made  of  marsh-mallows  or  flax-seed  tea, 
or  to  the  application  of  some  unctuous  material  to  these  parts,  and, 
above  all,  to  belladonna  ointment.  Where  the  labour  is  suspended, 
and  the  pains  become  languid,  the  spurred  rye  ought  to  be  adminis- 
tered, yet  not  until  we  feel  assured  that  the  mouth  of  the  womb  is 
sufficiently  dilated.  On  the  other  hand,  we  ought  always  to  reject 
as  hurtful  and  dangerous,  all  purgative  emetics,  irritating  injections, 
and  sternutatories,  prescribed  with  a view  to  arouse  the  pains  and 
augment  the  activity  of  the  labour.  In  fine,  when  the  neck  is  suffi- 
ciently open,  the  bag  of  waters  may  be  ruptured  by  gently  pressing 
the  finger-nail  against  the  protruding  membranes,  or  by  making  use 
of  the  point  of  a pair  of  scissors,  guided  by  the  index-finger. 

To  avoid,  as  far  as  possible,  the  laceration  of  the  perineum,  when 
that  part  is  distended  by  the  head  of  the  child,  which  has  reached 
the  vulva,  we  ought  not  only  to  support  the  perineum,  by  pressing 
the  palm  of  the  hand  against  the  perineum,  but  we  should  direct  the 
woman  to  refrain  from  bearing-down  efforts,  and  to  separate  her 
thighs  and  not  flex  them  too  much  on  the  pelvis,  so  that  the  parts 
being  put  less  upon  the  stretch,  may  mould  themselves  better  upon 
the  head  of  the  child. 

[I  must  caution  the  inexperienced  practitioner  not  to  incur  the  hazard  of 
rupturing  the  membranes  in  primiparous  women,  except  under  some  well- 
considered  necessity  for  that  act.  It  is  difficult,  in  such  persons,  to  foretell 
the  precise  amount  of  resistance  to  be  encountered  by  the  child  before  it 
can  escape  from  the  organs ; and  an  early  rupture  of  the  ovum  is  not  very 
rarely  followed  by  increased  delay  in  the  delivery  of  the  head, — but,  as  the 
child  is  thenceforth  subjected  to  the  unmitigated  pressure  of  the  womb, 


DELIVERY  OF  THE  SECUNDINES. 


701 


which  is  irritated  by  the  contact  of  the  child’s  body,  from  around  which  the 
waters  have  thus  been  removed,  the  woman  is  exposed  not  only  to  the  mis- 
hap of  giving  birth  to  a still-born  child,  but  she  runs  some  risk  of  being 
afterwards  subjected  to  a forceps  or  an  embryulcia  operation  for  her  delivery. 
I may  make  the  additional  remark,  that  the  reasons  for  supporting  the  peri- 
neum are  the  following: — Professor  Carus’s  curve  consists  in  an  arc  of  a 
circle  whose  radius  is  two  and  a half  inches,  and  which  may  be  described 
as  follows  : — Cut  a pelvis  in  two,  vertically,  from  front  to  rear,  with  a saw. 
Set  one  leg  of  a pair  of  compasses  upon  the  posterior  edge  of  the  bisected 
symphysis  pubis ; open  the  other  leg  two  and  a half  or  two  and  three- 
quarter  inches ; then  describe  a circle  through  the  pelvis,  from  top  to  bot- 
tom, and  carry  the  curve  up  in  front  of  the  pelvis.  This  curve  of  Professor 
Carus  is  the  curved  axis  of  the  pelvis, — and  the  centre  of  the  child’s  ence- 
phalon, in  the  act  of  being  born,  moves  coincidently  with  this  curved 
line.  Now,  when  the  accoucheur  supports  the  perineum,  he  does  so  with 
no  other  view  than  to  compel  the  head  to  move  coincidently  with  this 
curve,  or,  in  other  words,  to  prevent  it  from  descending  at  a tangent  to  the 
arc ; in  doing  which,  it  must  carry  away  the  perineum  or  rupture  it.  I do 
not  think  that  when  the  womb  is  thrusting  the  head  downwards,  we  ought 
to  prevent  the  descent  of  the  head ; for,  in  so  doing,  we  oppose  an  obstacle 
so  great  that  we  expose  the  patient  to  the  risk  of  laceration  of  the  womb  or 
vagina,  or  both.  If  we  compel  the  head  to  move  along,  in  the  direction  of 
Carus’s  curve,  and  exhort  the  patient  not  to  bear  down,  we  do  all  that  it 
behoves  us  to  do  for  her  interest  and  safety  in  the  premises. — M.] 

When  the  child  is  born,  we  should  next  attend  to  the  delivery  of 
the  after-birth,  which  is  generally  effected  by  a few  pains,  and  which 
may  be  facilitated  by  taking  hold  of  the  umbilical  cord  and  gently 
pulling  it  downwards.  After  this  operation,  which  the  accoucheur 
commonly  need  not  attend  to  until  after  he  shall  have  given  some 
attention  to  the  child,  the  vulva  must  be  cleansed,  as  well  as  all  the 
parts  that  are  soiled  with  the  discharges,  either  by  washing  them, 
with  pure  warm  water,  or  a mixture  of  wine  and  water,  where  the 
parts  appear  much  relaxed. 

The  woman  may  with  propriety  be  left  upon  her  cot,  as  long  as 
fluid  blood  continues  freely  to  flow  from  the  organs ; but  we  should 
not  too  long  delay  putting  her  into  the  bed  that  she  is  Vo  use  for  the 
rest  of  her  lying-in,  unless  some  haemorrhage,  convulsion  or  other 
accident,  the  consequence  of  extreme  weakness,  should  intervene. 
In  such  case,  we  ought  to  wait  awhile,  to  give  time  to  the  functions 
to  recover  their  natural  rate ; yet,  be  the  woman  ever  so  well,  she 
must  be  forbidden  to  rise  and  walk  to  her  bed,  for,  by  doing  so,  she 
exposes  herself  to  the  danger  of  having  some  displacement  of  the 
womb,  and  to  a thousand  other  accidents ; it  is  well,  even,  to  bring 
the  two  beds  side  by  side,  so  that  she  can  be  made  to  slide  from  one 
into  the  other,  almost  without  moving  her  body,  by  pulling  the  sheet 
on  which  she  laid  to  be  delivered. 


702 


PUTTING  TO  BED  — THE  BREASTS. 


Previously  to  transferring  her  to  her  bed,  we  ought  always  to 
direct  the  nurse  to  put  clean  linen  on  the  patient,  taking  care  that  it 
be  well  aired  first  and  moderately  warmed,  and  never  follow  the 
absurd  prejudice  that  pretends  that  a woman  ought  not  to  change 
her  linen  until  the  seventh  day  or  the  ninth  day  after  her  delivery. 

When  the  patient  is  comfortably  put  to  bed,  which,  in  cool  or 
damp  weather,  ought  to  be  warmed,  her  breasts  are  to  be  covered 
with  a soft  napkin  or  muslin  handkerchief,  folded  in  eight ; but  the 
breasts  ought  never  to  be  compressed,  nor  kept  immoderately  warm, 
nor  ought  we  to  allow  any  repercussive  or  astringent  poultice,  with 
a view  to  hinder  the  coming  of  the  milk.  The  same  rule  holds 
as  to  the  binder  for  the  belly,  which  ought  to  be  lightly  applied,  so 
as  to  be  merely  a contentive  bandage.  It  commonly  consists  of  a 
napkin,  folded  into  a triangle,  the  point  being  directed  towards  the 
vulva ; the  bandage  to  cover  the  hypogastrium,  is  a napkin  folded  in 
three,  lengthwise,  and  which  is  used  as  a body  bandage,  to  pass 
round  the  abdomen,  and  comprehending  the  hips.  To  prevent  this 
bandage  from  slipping,  or  becoming  uncomfortable,  it  should  be 
secured  to  straps  passing  over  the  shoulders,  like  a pair  of  suspenders. 
It  should  also  be  kept  down  by  attaching  to  it  the  two  ends  of  the 
napkin , to  be  used  by  the  woman  as  her  T bandage,  with  a view  to 
receive  the  lochial  discharges. 

[Let  me  again  caution  the  younger  reader  against  M.  C.,  with  whom  I 
cannot  here  agree.  The  napkin  is  to  be  used  as  a receiver.  If  it  be  too 
strongly  pressed  against  the  genital  fissure,  by  the  method  indicated  by  our 
author,  there  is  reason  to  fear  that  it  may  act  as  a tampon,  and  by  prevent- 
ing the  escape  of  coagula,  or  of  fluid  blood,  may  give  rise  to  a concealed 
haemorrhage. — M.] 

Inasmuch  as  when,  speaking  of  milk-fever,  of  the  lochia,  and  of 
inflammation  of  the  mamma;,  we  treated  of  other  cares  required,  as 
to  the  woman,  we  shall  rest  satisfied  here,  to  prevent  repetition,  with 
saying  that  the  woman  ought  to  be  in  a large  chamber,  well  venti- 
lated, warmed  in  the  winter  season,  but  with  the  air  renewed  once 
or  twice  a day,  by  opening  the  windows,  after  carefully  covering  the 
patient  and  closing  her  curtains.  A calm  state  of  mind,  and  rest  for 
the  body,  are  indispensable.  The  ancients  were  so  well  convinced 
of  the  usefulness  of  this  precept,  that,  at  Rome,  even  the  magistrate 
had  no  right  to  enter  the  house  of  a lying-in  woman,  to  execute  a 
sentence.  Juvenal  says,  that  in  order  that  all  the  citizens  might 
respect  this  asylum,  it  was  necessary  merely  to  suspend  a garland  at 
the  door. 

Foribus  suspende  coronas, 

Jam  pater  es 

The  visits  of  friends,  neighbours  and  acquaintances,  ceremonious 
visits,  and  calls  of  relatives,  are  among  the  frequent  causes  to  which 
may  be  attributed  a variety  of  diseases  of  the  lying-in  woman,  that 
lead  to  the  most  serious  consequences. 

The  time  that  a woman  ought  to  remain  in  bed,  is  necessarily  very 


DIES  MUNDINiE. 


703 


variable ; and  the  fixed  term  of  nine  days,  adopted  by  the  vulgar, 
can  only  be  so  as  a mean  and  general  term.  In  some  instances,  six 
days  are  sufficient ; whereas,  in  other  cases,  fifteen,  and  even  twenty 
days,  are  indispensable,  particularly  where  the  symphyses  have  been 
strained,  where  the  womb  is  disposed  to  prolapsion,  and  where  the 
general  health  is  precarious.  Furthermore,  the  first  trial  of  sitting 
up  should  not  be  protracted  beyond  half  an  hour,  or  an  hour  at  most, 
upon  a couch  or  sofa ; but  women  ought  never  to  consecrate  their 
first  going  out  to  a visit  to  the  church,  to  perform  what  is  called  their 
relevuilles.  The  cold  damp  air  of  a church,  the  kneeling  posture  in 
which  they  place  themselves,  expose  them  to  dangerous  attacks. 
Enlightened  and  true  religion  would  forbid  such  imprudences,  and 
ordains  rather,  that  previously  to  proceeding  to  the  church  to  return 
thanks  to  God  for  her  recovery,  the  lying-in  woman  should  first 
recover  her  strength  at  home,  and  go  out  only  during  the  fine 
weather,  and  not  until  she  is  satisfied  she  can  venture  into  the  air 
without  hazard.  There  is  another  custom  that  requires  the  strict 
care  of  the  physician,  to  wit,  the  baptismal  feast,  at  which  the  lying- 
in  woman  ought  not  to  be  present,  unless  it  take  place  after  the  tenth 
day,  and  even  then  she  should  take  great  care  lest  the  days  of  re- 
joicing should  be  followed  by  days  of  mourning. 


INDEX 


OF 

AUTHORS  REFERRED  TO. 


Aetius,  65,  74,  80,  81,  121,  152,  154,  165, 
284,  293,  381,  384,  400,  452,  483,  495, 
513,  514,  519,  529,  533,  654. 

Ahrun,  519. 

Albers,  578. 

Alberti,  519,  529. 

Albinus,  381,  493. 

Albucasis,  65,  74,  82,  134. 

Alibert,  309,  320,  322,  343,  408, 445,  488. 
Aliiot,  Pere,  451. 

Amard,  519. 

Ameline,  155,  169. 

Amussat,  382,  453,  476,  477. 

Andral,  107,  381,411,412,420,421,422, 
496,  497,  503,  513,  524,  662. 
Andrieux,  476. 

Ane,  177,  182. 

Antillus,  121. 

Antipater,  400. 

Archigenes,  65,  452. 

Aretaeus,  121,  307,  513,  519,  529,  537, 
654. 

Aristotle,  24,  31,  87,  121,  571. 

Armstrong,  286,  655,  661,  668,  679. 
Arnaud,  77,  113. 

Arnault,  578,  580. 

Arronssohn,  360. 

Asdrubali,  220. 

Aspasia,  121,  154,  165. 

Assalini,  456. 

Astruc,  25,  32, 152, 284,  313, 314, 368,  377, 
519,  578,  579. 

Atlee,  417. 

Avenel,  348. 

Avicenna,  65,  74,  82,  90,  307, 452,  495. 
Aumonier,  417. 

Babin,  198. 

Bache,  F.,  183. 

Baer,  381. 

Baglivi,  314. 

Baillie,  238,  421. 

Baillou,  313,  314,  495,  512,  519,  696. 
Bailly,  524. 

45 


Ballard,  511. 

Banks,  44. 

Barbaut,  55,  261,  580. 

Barbeyrac,  519. 

Barlet,  157. 

Barnes,  243. 

Barret,  198. 

Barruel,  499. 

Barry,  28,  460,  576. 

Barthelemi,  Emile,  220,  223. 

Barthez,  519. 

Bartholin,  of  Copenhagen,  76,  215,  235, 
282,  696. 

Barton,  J.  Rhea,  263,  266,  444. 

Basil,  St.,  517. 

Baudelocque,  32,  118,  155,  162,  169,  177, 
179,  182,  190,  193,  203,  219,  233,346, 
367,  370,  395,  407,  465,  470,  578,  579, 
580,  668. 

Baudelocque,  the  younger,  669,  677,  678. 
Bauhin,  75,  93,  143. 

Baumes,  519. 

Baumgarten,  168. 

Bauner,  364. 

Baxter,  152. 

Bayle,  335,  446,  581. 

Baynham,  167. 

Bazin  de  Basseneville,  155. 

Bazoni,  322. 

Beau,  501. 

Beaujon,  258. 

Beaulieu,  143. 

Beauregard,  234. 

Beckerus,  76. 

Bedard,  407. 

Begin,  453, 469. 

Beherens,  586. 

Behling,  234. 

Bell,  Benjamin,  314,  370,453. 

Charles,  448. 

Thomas,  580,  584. 

Bellanger,  163,  164. 

Bellemain,  578. 

Bellini,  247,  365. 


706 


INDEX  OF  AUTHORS  REFERRED  TO, 


Bellon,  80. 

Benedicti,  368. 

Benevenius,  88,  152. 

Benevoli,  105,  114. 

Beniveni,  77. 

Benoiston  de  Chateau-Neuf,  42. 

Berard,  Auguste,  26,  147,  151,  214,  408. 
Berner,  501. 

Bernhard,  152. 

Berthelot,  353. 

Berthold,  586. 

Bertholini,  T.,  211. 

Bertrand,  353. 

Bertze,  65. 

Bessiere,  198. 

Bianchi,  574. 

Bichat,  29,  54,  308,  381,  386,  519,  521, 
533. 

Bicknell,  207. 

Biett,  448. 

Billard,  198,  199. 

Binninger,  519,  note. 

Birbeck,  James  B.,  577. 

Bird,  155,  417. 

Bischoff,  26,  28,  34,  460,  576. 

Blache,  496. 

Blackmore,  519. 

Blancard,  375,  382,  433,  516. 

Blandin,  354,  355,  386. 

Blasius,  165. 

Blaud,  474,  496,  502,  509,  510. 

Blanche,  581. 

Blayn,  496. 

Blegny,  516. 

Blizard,  580. 

Blundell,  241,  364,  416,  428. 
Bobe-Moreau,  131. 

Bochard,  233. 

Bocquet,  322. 

Boehmer,  127. 

Boer,  158,  169,  225. 

Boerhaave,  280,  381,  501,  514,  519,  529, 
536,  595. 

Boisseau,  496,  520. 

Boivin,  Mad.,  65,68,  79, 132, 155, 156,  163, 
164,  169,  170,  172,  176,  188,  191,  193, 
198,  324,  374,  412,  427,  429. 

Bond,  H.,  594. 

Bonfils,  355,  469. 

Bonnet,  Theoph.,  234,  307,  375,  382,  496. 
Bonnie,  575. 

Bordeu,  29. 

Bosquillon,  654. 

Bouchard,  581. 

Bouchardet,  485. 

Bouchet,  of  Lyons,  189,  404. 

Boudet,  217. 

Boudon,  245,  390,  395,  400. 

Bouillaud,  496,  500,  501. 

Bourgeois,  Louise,  615,  680. 

Bourjot,  St.  Hilaire,  486. 

Bousquet,  54. 

Bouteillier,  633. 

Bouvet,  385. 


Boyer,  99, 114, 118, 143, 145,  150, 168, 178, 
195,  201,  214,  246,  355,  388,  404,  409, 
445,  451,452,453. 

Boyle,  386. 

Brachet,  496,  519,  536,  538,  539. 

Brainerd,  Daniel,  98,  99. 

.Brande,  485. 

Brasador,  401. 

Braun,  451. 

Brem,  411.  , 

Bremser,  381. 

Brendelius,  228. 

Brera,  470,  476. 

Breschet,  52,  54,  355,  381,  385,  386,  578, 
580,  662. 

Breyer,  584. 

Bricheteau,  578. 

Brierre  de  Boismont,  22,  33,  39,  485. 
Brodie,  148. 

Bromfield,  382. 

Brouard,  144. 

Broussais,  Casimir,  468,  536,  655,  660. 
Broussonnet,  310. 

Brown,  R.,  429,  654. 

Brueck,  496. 

Brugnatelli,  382. 

Brunninghausen,  142,  155. 

Bruyer,  575. 

Bry  de  Bouillon,  575. 

Buchan,  561. 

Buchner,  501. 

BufFon,  514. 

Bugniard,  451. 

Buisson,  54. 

Burnet,  Tho.,  519. 

Burns,  of  Glasgow,  203,  208,  330,  429,  634. 
Bussidre,  574. 

Cabanis,  496. 

Cabaret,  113. 

Cabini,  493. 

Cabrol,  86,  88,  113. 

Caignoux,  355. 

Caillot,  54,  118,  434. 

Callisen,  158,  429. 

Camerarius,  76. 

Campbell,  233. 

Camper,  147,  198,  429,  453. 

Canella,  355. 

Canonico,  580. 

Cappivacci,  451,  534. 

Capuron,  132,  150,  241. 

Carget,  of  Pampeluna,  162. 

Carron  de  Villards,  100,  342,  476. 
Carmichael,  451. 

Carpue,  189. 

Carpus,  152. 

Carus,  218,  578,  701. 

Castro,  Rod.  a,  38,  154,  309,  314,  495,  496, 
571. 

Cayol,  335,  446,  654. 

Cazeaux.  287,  291. 

Celsus,  74,  89,  90,  92,  385,  400,  452,  485, 
513,  530,  654. 


INDEX  OF  AUTHORS  REFERRED  TO, 


707 


Cerlata,  452. 

Chailly,  244,  287. 

Chambon,  77,  93,  523. 

Chapman,  641. 

Chapponnier,  476,  note. 

Chardin,  80. 

Charleton,  307,  313. 

Charriere,  65,  341. 

Charlton,  314,  519. 

Chassaignac,  407. 

Chassagne,  Dufresne,  259. 

Chatelain,  469. 

Chaussier,  201,  202,  226,  285,  556,  575, 
654,  655,  660,  662. 

Chelins,  249. 

Chesneau,  519. 

Chester,  429. 

Cheselden,  452. 

Chevalier,  92. 

Chit,  578. 

Chomel,  654. 


Christian,  of  Liverpool,  201,  202. 
Christophe  de  Vega,  152. 

Chrysmer,  417,  432. 

Churchill,  174,418,  419. 

Fleetwood,  321,  416. 

Cigna,  276. 

Civatte  de  Siteron,  52. 

Clarke,  152,  155,  401,  486,  575,  616,  662. 
Claubry,  396. 

Clay,  417,  418. 

Cleghorn,  429. 

Clifton,  25. 

Cloquet,  Jules,  127, 144, 146,  209, 390, 453, 
480,  518. 

M.  H.,  381,537. 

Cocke  tt,  155. 

Coelius  Aurelianus,  519,  530. 

Coindet,  476, 535. 

Colin,  390. 

Collineau,  233,  325. 

Collins,  of  Dublin,  632,  637,  676,  677. 
Colomb,  of  Lyons,  584. 

Colombus,  118. 

Columella,  31. 

Comarmond,  486. 

Come,  188,  451,  456. 

Condon,  105. 

Cooper,  Sir  Astley,  201,  202, 204, 208,  209, 
432,  457,  458. 

B.,  417. 

Samuel,  201, 429,  453. 

Copping,  577. 

Copland,  499. 

Corbin,  448,  note. 

Cormick,  107,  108. 

Corriol,  473,  note. 

Coste,  Baer,  28,  460. 

Coster,  517. 

Courtial,  576,  578. 

Crantz,  232. 

Cromer,  553. 


Crosse,  J.  Greene,  184. 

Crouzit,  268. 

Cruveilhier,  332,  355,  377,  381,  390,  391, 

421,  422,  423,  434,  580,  662. 

Cullen,  460,  476,  492,  496,  519,  536. 
Cullerier,  26,  178,  263,  315,  325. 

Curade  d’Avignon,  201,  202. 

Cypriaan,  575,  580, 584. 

Daillez,  175,  179,  182. 

Dance,  277,  578,  662,  664. 

Darwin,  431. 

Duverney,  54. 

David,  of  Rouen,  401. 

D.,  684. 

Davies,  D.,  669. 

Davis,  John,  396. 

Davy,  485. 

De  Cordibus,  367. 

Deganosse,  355. 

De  Graaff,  25,  28,  122,  307,  313,  381,  385, 
460, 574. 

Dehaen,  32,  107,  204,  205,  206,  429,  430, 
431,433. 

D’Huc,  203. 

Deidier,  451. 

Dejours,  107. 

Delaberge,  Louis,  464,  471,  499. 

De  la  Corde,  Maurice. 

De  la  Croce,  Andreas,  65. 

Delamotte,  134,  179,  220,  232,  367,  486, 
626,  639. 

Delaporte,  430,  431,  432. 

Delaroche,  655. 

Delaunay,  Ch.,  577. 

Deleau,  143. 

Deleurie,  189. 

Delisle,  580. 

Delloir,  151. 

Deloob,  519. 

Delpech,  113,  153, 176,  219,  247,  362,  366, 

422,  423,  429,  432. 

Demarchais,  80. 

Deneux,  169,  198,  199,  218,  225,  227,  373, 
406,  431,  655. 

Denis,  485. 

Denman,  157,  169,  170,  178,219,232,386, 
427,  429. 

Dessault,  188,  190,  227,  245,  246,  386,  391, 
401,453,  455, 456. 

Deschamps,  153,  250,  262. 

Desgranges,  113,  155. 

Desmarais,  377. 

Desormeaux,  143,  162,  165,  169,  177,  210, 
219,  231,  381,  464,  492,  496,  512,  583, 
585,  633. 

Devaux,  128,228. 

De  Vega,  368,  370. 

Deveux,  367. 

Deventer,  Henry,  173,  174,  232. 

Dewees,  165,  186,  187,  271,  593,  614,  641 
Deyber,  65,  250. 

Dezeimeris,  287. 

Diemerbroeck,  78,  224,  431,  519. 


70S 


INDEX  OF  AUTHORS  REFERRED  TO, 


Dieterich,  451. 

Dieffenbach,  213,  220,  223,  252,  418,  433. 
Diogenes  Laertius,  529. 

Dionis,  82,  284,  401,  453,  485,  577. 

Divoux,  201.  ' 

Dobson,  32. 

Dodonceus,  367. 

Daering,  196. 

Doloeus,  Jean,  309. 

Dolhoff,  417,  418. 

Donatus  Marcellus,  76,  235,  376,  382. 
Donne,  275,  315,  316,  321,  485. 

Doublet,  654,  659,  660. 

Douglass,  234. 

Doulcet,  660. 

Dowman,  451. 

Dubois,  A.,  65, 179, 190,  356, 401,  409, 451, 
464,  518,  569,  632,  655. 

Dubois  de  la  Boe,  536. 

Dubois,  Paul,  26. 

Thibaud,  237. 

d’Amiens,  529  note , 536. 

Dubled,  365. 

Ducreux,  127, 150. 

Dufrenois,  322. 

Duges,  '25,  79,  80,  132,  143,  150,  151,  156, ; 
163,  167,  169,  170,  171,  172, 176,  188,  j 
190,  191, 192,  193,  209,  252,  324,  330, ! 
374,  376,  386,  412,  496,  514,  519. 
Dumeril,  476. 

Dumoulin,  519. 

Dunn,  John,  235. 

Dunus,  367. 

Duparcque,  232,  233,  241,  299,  300,  302, 1 
303,  304,  305,  330,  339,  493. 

Dupuys,  499. 

Dupuytren,  77,  93,  116,  118,  147,  201,213, ! 
219,  220,  222,  246,  247,  258,  261,  267,  ! 
323,  344, 349,  354,  355,  373,  386,  387,  | 
389,  390,  392,  401,  404,  406,  408,409, 1 
411,529,  451,453,  455,  456. 

Duret,  422,  519,  533. 

Dussaussoy,  164. 

Duval,  128. 

Duvernoy,  574. 

Pzondi,  432. 

Egge,  232. 

Ehrmann,  250. 

Emett,  25. 

Engel,  54,  118. 

Erasistratus,  513. 

Ergot,  341, 477. 

Esqnirol,  518. 

Ettmuller,  318,  495,  517,  654. 

Evratt,  451. 

Eydoux,  473,  note , 474. 

Fabre,  355. 

Fabricius  ab  Aquapendente,  88. 

Faivre,  153,  189. 

Fallopius,  401. 

Fatio,  249. 

Fearon,  339,  447,  451. 


Feburier,  243. 

Fern,  578. 

Fernel,  309,  314,  376,  519,  570. 

Ferrand,  176,  185. 

Ferrin,  107. 

Fincke,  487,  492. 

Fitzgerald,  32. 

Flamand,  91,  92,  93, 105,  113,  114,  477. 
Fodere,  30,  69,  107,  110,  118. 

Foedich,  513. 

Fonseca,  318. 

Fontenelle,  Julia,  485. 

Ford,  429. 

Forestus,  220,  318,  496,  519. 

F othergill,  42. 

Foubert,  453,  456. 

Fourcroy,  451. 

Foville,  519,  536. 

Fox,  George,  182,  186. 

Franck,  113,  367,  368,  431,  433,  496. 
Freind,  32,  308,  470,  496. 

Fresart,  P.,  314. 

Fritz,  477. 

Fritzel,  237. 

Fronton,  406. 

Fuchs,  451. 

Gaddesdex,  451. 

Gall,  24. 

Galen,  25,  32,  75,  81,  284,  305,  307,  318, 
339,  347,  354,  355,  373,  385,  386,  387, 
389,  390,  392,  401,  404,  406,  408,409, 
411,  429, 447,  451,  453,  455,  456,  495, 
496,513,  519,  571,  654,  675. 
Galenzowski,  432. 

Gardien,  54,  168,  178,  182,  431,  469,  492, 
496,  502,  512,  519,  536. 

Garengeot,  65,  205,  429,  453. 

Garin,  127. 

Garthshore,  155. 

Gasc,  678. 

Gattinaria,  Marcus,  152. 

Gauthier,  113. 

Gendrin,  25,  26,  27,  28,  34,  365,  461. 
Gensoul,  404. 

Genselius,  586. 

Georget,  514,  519,  528,  536. 

Gerard,  Chs.,  536. 

Gerdy,  386. 

Gerentel,  518. 

Gesner,  516. 

Gilbert,  83,  475. 

Girardin,  151. 

Giroud,  132. 

Goldson,  234. 

Goliken,  318. 

Gooch,  189. 

Gordon,  of  Aberdeen,  286,  420,  655,  661, 
672.  679,  681. 

Gorter,  32,  519. 

Goulard,  178,  215,  451. 

Goubelly,  540. 

Gradibus,  J.  Math,  de,  367,  370. 

Graaff,  31. 


INDEX  OF  AUTHORS  REFERRED  TO. 


709 


Grsefe,  518. 

Grainger,  386. 

Grammont,  134. 

Grandpre,  451. 

Granville,  189,417,418,  576. 

Gregoire,  154. 

Greenhow,  417. 

Grenier,  148,  267. 

Grenville,  427,  432,  433. 

Grownhawn,  586. 

Guerin,  266. 

Guenee,  354. 

Guersant,  223. 

Guerbois,  262. 

Guillemeau,  93. 

Guillon,  65,  143,  356,  360. 

Gutberlat,  362. 

Hagendorix,  211. 

Hahnemann,  341. 

Hall,  Marshall,  151. 

Halle,  320,  432. 

Haller,  32,  38,  59,  119,  126,  135,  198,  428, 
465,  470,  519,  536. 

Hamilton,  496,  512,  520,  536,  679. 
Hanneman,  571. 

Hargraves,  419. 

Hatin,  Jules,  100,  322,  355,  356. 

Hay,  263,  264,  431,  578. 

Heath,  418. 

Hecker,  J.  F.  C.,  567. 

Heidenrich,  578. 

Heister,  76,  110,  113,  211,  222,  339,  401, 
452. 

Helvetius,  561. 

Heming,  213. 

Herbin,  578. 

Herbiniaux,  179,  386,  398,401,406,408, 
409. 

Hertry,  577. 

Hervez  de  Chegoin,  115,  136,  155,  386, 
389,  406,  408,  409. 

Heurnius,  307. 

Hey,  286,  429,  655,  668,  674,  679. 
Hildanus,  88,  91,  196,  239,  241,  244,  245, 
445. 

Hill,  James,  453. 

Hilscher,  245. 

Hippocrates,  31,  32,  42,  87,  93,  94,  121, 
154,  176,  276,  305,  307,  312,  317,  318, 
38 1,385,  400,  40 1 , 447, 472, 476,  492, 
495,  513,  519,  533,  566,  571,  585,  654, 
696. 

Hoechstetter,  367. 

Hoelscher,  363. 

Hodge,  183. 

Hoffman,  25,  227,  284,  307,  318,  385,  389, 
476,  488,  492,  493,  496,512. 

T.,  519,  525,  531,  536. 

Hoffmeister,  578. 

Hoin,  188,  203,  205,  213. 

Holt,  Ths.,  233. 

Home,  SirEverard,  198. 

Hooper,  155,  330,  422,  436. 


Horace,  72. 

Horn,  127,  131,  654. 

Horner,  95. 

Howship,  429. 

Huerman,  377, 453. 

Hufeland,  305,  339,  447. 

Huguier,  395,  396,  426. 

Hunalt,  520,  536. 

Hunter,  G.,  429. 

Wm,  59,  631,  632,  666. 

Jno.,  141,  155,  157,  167,  168,  384, 

429,  433,  485. 

Husson,  465,  662. 

Huston,  B.  M.,  103,  207,  636. 

Hutchinson,  509. 

Hygmore,  520,  529. 

Imbert,  451. 

Irving,  151. 

Ischier,  432. 

Itard,  376. 

Jacquemin,  325. 

Jadelot,  53. 

Jahn,  155,  168. 

James,  182,  186,  580. 

Janot,  587. 

Jauzion,  516. 

Jeafferson,  417. 

Jean  Maria,  536. 

Jewel,  116,  118. 

Jobert,  324. 

Johnson,  429. 

W.  P.,  151,  189. 

Jolly,  516. 

Jones,  28,  460. 

Josephi,  584. 

Joubert,  30,  65,  368, 370,  382,  597. 
Jourdan,  26. 

Jourel,  167. 

Jouy,  577. 

Junot,  492. 

Justamont,  451. 

Juvenal,  514. 

Kaetschmxtt,  386. 

Kapp,  451. 

Kapser,  432. 

Kelni,  577. 

Kempel,  341. 

Kennedy,  Evory,  70,  570. 

Kerckring,  127,  476. 

Kergaradec,  69. 

Key,  417,  430. 

King,  417,  418. 

Kinneir,  Douglas,  661. 

Kirshner,  155,  156. 

Klein,  155,  529. 

Koeller,  385. 

Kravel,  346. 

Kruger,  578,  579. 

Labare  de  Benzeville,  182., 

Labarraque,  273. 

Lachaise,  547. 


710 


INDEX  OF  AUTHORS  REFERRED  TO. 


Lachapelle,  Mad.,  193,  219,  225,  5S5,  587, 1 
633. 

Lacombe,  457. 

Laennec,  378,  381,  428. 

Lafflize,  of  Nantes,  432. 

Lagneau,  314,  355. 

Lallemand,  163,  164,  241,  257,  258,  447. 
Lallement,  54,  194,  195,  198,  578,  579. 
LambaUe,  J.  J.  de,  260. 

Lambergen,  451. 

Lambron,  237. 

Lamothe,  654. 

Lamoite,  280,  569. 

Larnzweerde,  386,  571. 

Lancisi,  529. 

Lane,  417. 

Lanfranc,  452. 

Langenbeck,  153,  362,  363,  364. 

Langius,  152,  227,  495. 

Lankrisch,  385. 

Lapeyronie,  346. 

La  Pitie,  63. 

Lapoterie,  456. 

Largus,  Scribonius,  400. 

Laroche,  143,  404. 

Laroux,  182. 

Larrey,  212,  298,  344,  600. 

Lartet,  578. 

Lassus,  198,  199,  200,  431,  445. 

Latham,  429. 

Latour,  92,  114. 

Laugier,  259,  401,  578. 

Laumonier,  412. 

Lauvariol,  346. 

Lauverjeat,  188,  198,  645. 

Lavagna,  485. 

Leake,  662. 

Leblanc,  131,  177,  203,  205,  206,  404. 
Lecat,  25,  401,  452. 

Lecanut,  485,  513. 

Lecieux,  235. 

Leduc,  366. 

Ledran,  305,  423,  429,  430,  447,  452,  456. 
Lee,  21,  25,  27,  28,  34,  286,  461,  521,  643, 
646,  669,  671,  684. 

Lefevre,  567. 

Leger  de  Gouey,  575,  612. 

Legouais,  667,  668,  669,  674. 

Lejeune,  409. 

Lemman,  432. 

Lemaunoir,  432. 

Leonard  de  Bertapaglia,  552. 

Leonidas,  452. 

Leo  Africanus,  80. 

Lepecq-de-la-Cloture,  696. 

Lepine,  261. 

Lepis,  Chas.,  536. 

Lepois,  519,  529,  536. 

Le  Roux,  54,  175. 

Le  Roy,  492,  536. 

Lesne,  249. 

Lesueur,  44,  341. 

Levaillant,  44. 

Levannier,  404. 


Leveille,  131. 

Levis,  183. 

Levret,  82,  107,  134,  155,  158,  162,  166, 
169,  174,  175,  179,  213,  232,  386,  389, 
394,  395,401,  404,  406,  518,  615,  654, 
659. 

Lewzinski,  249,  250. 

L’Heritier,  471,  note. 

Liebaud,  314. 

Lieutaud,  54,  107,  118,  281,  382,  432,  519. 
Linnaeus,  32,  519. 

Lisfranc,  24, 45, 46, 47, 49, 50, 52, 54, 57, 63, 
65,  122,  147,  295,  297,  299,  305,  323, 
333,  336,  339,  341,  344,  345,  347,  348, 
350,  357,  358,  359,  361,  370,  401,  406, 
408,  409,  447,  448,  450,  453,  455,  471, 
475,  495,519,  535. 

Littre,  575. 

Lizar.s,  of  Edinburgh,  364,  415,  417,  418, 
429,  430,  432,  433. 

Lobstein,  25,  406. 

Locock,  427. 

Loder,  127,  211. 

Loefler,  401. 

Logger,  421. 

Lordat,  492. 

Lory,  519,  529. 

Loudon,  476,  512. 

Louis,  381,  382,  456,  662. 

Louyer  Villermay,  514,  519,  532,536,540. 
Lugol,  474. 

Lycurgus,  546. 

Macdowei,  432. 

Mackenzie,  237. 

Mackintosh,  480,  481,  565,  666,  668,  669, 
679. 

Magendie,  32,  476. 

Mahon,  110. 

Major,  69. 

Malagodi,  251. 

Malgaigne,  341,  386,  387,  391,  399. 

Mallat,  486. 

Mainaldus,  577. 

Manning,  234. 

Marat,  678. 

Marcus  Aurelius. 

Maret,  194. 

Marignes,  126,  150. 

Marjolin,  153,  324,  345,  355,  389. 
Marshall,  152,213,  421. 

Martial,  82. 

Martin,  M.  H.,  383,  418,  432. 

, 114,  575. 

Martineau,  429. 

Martini,  of  Lubeck,  430. 

Masuyer,  480. 

Mathias,  82. 

Mauduyt,  476,  512. 

Maune,  390. 

Maunsel,  Wm.,  124. 

Mauriceau,  81,  82,  88,  122,  126,  127,  131, 
132,  148,  150,  176,  281,  284,  314,  315, 
367,  376,  389,  570,  587,  639,  698. 


INDEX  OF  AUTHORS  REFERRED  TO. 


711 


Mayer,  of  Bonn,  52,  386,  409,  578,  661. 
Mayor,  of  Berlin,  405,  580. 

Mayor,  of  Lausanne,  298,  360,  401,  404. 
McDowell,  417,  418. 

Mead,  24,  427. 

Meckel,  46,  157,  421,  578,  662. 

Meckren,  88,  213,  215. 

Meisner,  401. 

Menier,  578. 

Mercatus,  315,  470,  495,  512,  519. 
Mercurialis,  284,  571. 

Merklin,  425. 

Merriman,  155,  157,  639,  649. 

Metzer,  118. 

Meudon,  429. 

Michaelis,  654. 

Miguet,  344. 

Miller,  337,  339. 

Millot,  188. 

Mcehring,  183. 

Mojon,  485,  581. 

Monneret,  464,  471,  499. 

Monfalcon,  409. 

Monro,  122,  376,  377,  422,  427,  429,  431, 
452,  453. 

Montaigne,  262. 

Montain,  220. 

Montana,  235. 

Montanier,  575. 

Monteggia,  246,  346. 

Montpelier,  170. 

Morand,  108,  135,  211,  381,  422,  431. 
Moreau  de  la  Sarthe,31,  41, 131,  218,  287. 
Morlane,  235. 

Morland,  114. 

Morgagni,  89,  91,  92,  105,  107,  110,  113, 
116,  119,  193,  281,  307,  309,  310,  339, 
381,  431,  434,  457,  516,  519,  536, 585. 
Morris,  417. 

Morton,  690. 

Morus,  Michael,  382. 

Moschion,  82,  88,  386,  406,  513,  514,  571. 
Mott,  Valentine,  266. 

Moudot,  578. 

Moulin,  231,  232,  233,  578. 

Muratt,  Jean,  88,  194,  198,  406,412,421, 
431. 

Murey,  52. 

Murel,  42. 

Murray,  155. 

Musa,  Anthonius,  400. 

Mutter,  116,  219. 

Muzeau,  448,  450. 

Naboth,  110,  113. 

Nsegele,  250,  370,  376. 

Nathan,  432. 

Nauche,  70,  126,  166,  172,  237,  376,  382, 
412,  428,  476,512,  690. 

Negri,  322,  493. 

Negrier,  25,  26,  27,  28,  34,  461,  462. 
Neuter,  G.  P.,  309,  519. 

Neuville,  237. 

Newnham,  152,  189. 


Nicholson,  21. 

Nicod,  446. 

Nicoton,  119. 

Noel,  220. 

Nollet,  John,  147. 

Norford,  451. 

Norris,  George,  83. 

North,  453. 

Novarra,  580. 

Nysten,  401. 

Ochmar,  453. 

Ollivier  d’Angers,  26,  468. 

Orfila,  39,  261,  537. 

Oribasius,  198,  284,  513. 

Osborn,  492. 

Osiander,  25,  30,  134,  149,  189,  342,  346, 
347. 

Ovid,  499,  517,  696. 

Palella,  241,  245. 

Pallas,  381. 

Papen,.  198. 

Paracelsus,  25,  451. 

Pare,  65,  75,  93,  128,  152,  339,  346,  368, 
370,  386,  529,  534. 

Paroisse,  432. 

Pasta,  32,  284. 

Patterson,  476,  478. 

Patin,  480. 

Patuna,  578,  580. 

Paulus  JEginetta,  65,  75,  80,  82,  152,  293, 
452,  453,  495,  513,  516. 

Pauly,  24,  49,  54,  305,  333,  341,  477. 

Pe,  Lazare,  314. 

Pearson,  448. 

Pechlin,  470. 

Pecquet,  382. 

Pelletier,  251. 

Percy,  379,  381. 

Peron,  44. 

Perreau,  662. 

Perry,  519. 

Petit  Radel,  404,  428,  552. 

, J.  L.,  197,  243,  249,  453,  455,  575. 

, M.  A.,  107,  190,  305,  447. 

Peu,  234,  241. 

Peyrille,  152,  451. 

Philips,  B.,  417. 

Philotenus,  385,  401,  406. 

Philoxenes,  400. 

Physick,  141,  593,  630. 

Pidoux,  537. 

Piesch,  211. 

Pignana,  493. 

Pimpernelle,  453. 

Pinault,  Severin,  307. 

Pinel,  308,  314,  496,  518,  519,  655. 

Piorry,  471,  476. 

Pirminius  Gassarus,  577. 

Pissier,  451. 

Pitcairn,  313,  519,  520,536. 

Planchon,  228. 

| Plato,  57,476,519, 546. 


712 


INDEX  OF  AUTHORS  REFERRED  TO, 


Plater,  76,  431. 

Flazzoni,  107,  224. 

Plenck,  110,  114. 

Pliny,  25,31,38,74,514.  529. 

Plunket,  451,  note. 

Pomme,  519,  523,  529,  536,  540. 

Poot,  431. 

Portal,  54, 126, 127,  150,  368,  392, 421, 428, 
429,430,  431. 

Potts,  198,  200,347. 

Pouchet,  482,  568. 

Pousse,  L.  M.,  457. 

Pouteau,  147,  234,  305,441,445,  447,  654. 
Powel,  237. 

Power,  431. 

Pressavin,  519. 

Preuner,  143. 

Primrose,  314,  496,  519. 

Prochaska,  436. 

Pujol,  of  Castre,  519. 

, of  Montpellier,  496,  499. 

Purcel,  168,  530,  536. 

Purkinje,  28,  460,  460. 

Puzin,  233. 

Puzos,  178,  376,  587,  615,  641,  642,  654, 
659. 

QuARijr,  322. 

Quenesville,  507,  511. 

Quettenbaum,  417. 

Raciborski,  21,  26,  28,  29,  461,  510,  511. 
Radamet,  287. 

Radel,  428. 

Radford,  234. 

Rahn,  496. 

Rameaux,  471,  note. 

Ramsden,  430,  431. 

Ramsbotham,  580. 

Ranchin,  495. 

Randolph,  Jo.,  102. 

Rapon,  519. 

Raspail,  381. 

Rast,  of  Lyons,  318. 

Rauque,  690. 

Raulin,  310,  519,  529,  536. 

Raymond,  313,  470. 

Recamier,  65,  67,  143,  152,  259,  305,  333, 
341,  344,  347,  354,  355,  361,  364,  365, 
366,  400,  401,  408,  447,  448,  452,  476, 
493,  535. 

Rech,  514. 

Rega,  58. 

Regnard,  557. 

Reichard,  227. 

Renauldin,  54. 

Renaulme,  452. 

Reusner,  451. 

Reuss,  381. 

Rey,  190,  225. 

Rhazes,  452. 

Ribes,  662. 

Richerand,  314,  390,453,  456,  457,  518. 
Richter,  155,  205,  211,  213,  429,  431. 


Ricord,  65,  262,  276,  314,  315,  321,  322. 
Ricque,  65. 

Rideux,  572. 

! Ridley,  519. 

| Riolan,  jun.,  76,  106,  519,  574. 
j Ritter,  417. 

Riverius,  318,  491,  519,  596. 

Robert  de  Lille,  201,  202,  203. 

Robouham,  252. 

Roche,  201,  464,  496. 

Roderick,  404. 

Roederer,  232. 

Rogers,  D.,  417. 

Rognetta,  135,  136,  145,  166,  201. 
Romieux,  578. 

Rondelet,  30. 

Rondelou,  488. 

Rondet,  Mad.,  136,  201. 

Ronseeus,  470. 

Roonhuysen,  76,  88,  249. 

Rooselot,  451. 

Rostan,  465,  537,  561. 

Rouget,  687. 

Rougemont,  198. 

Rousseau,  492. 

Roussel,  24,  37,  134,  189,  227,  459,  569. 
Rousset,  152,  197,  198,  452. 

Roux,  135,  220,  221,  222,  223,  250,  252, 
366,  382,  386,  391,  445,  453,  477. 

, A.,  147. 

Royer  Collard,  470. 

Ruan,  91,271. 

Rufus,  513. 

Rullier,  519,  528. 

Runge,  580. 

Rungius,  234,  575. 

Rush,  673. 

Ruysch,  46,  88,  91,  127, 150,  153,  193, 197, 
198,  203,  262,  381,  382,  389. 

Ryan,  241. 

Sabatier,  131,  134,  147,  148,  164,  237, 
383,  394,  529,  431,  453,  457. 
Sablairoles,  476. 

Saisard,  54. 

Salathe,  287,  288. 

Salmuti,  235,  368. 

Sanctorius,  379. 

Sandifort,  201,  202. 

Sanson,  201,  244,  453,  464. 

Saucerotte,  220. 

Sauker,  519. 

Saumet,  107. 

Sauter,  of  Constance,  362,  364,  365,  494. 
Sauvages,  176,  315,  368,  496,  519,  534. 
j Savage,  495. 

Savary,  655. 

Saviard,  88,  122,  127,  128,  131,  143. 
Saxtorph,  155,  197. 

Scarpa,  201,  208,  209,  453. 

Schacher,  211,  212,  386. 

Schacht,  519. 

Schenck,  John,  88,  382. 

Schenck,  of  Nuremburg,  375. 


INDEX  OF  AUTHORS  REFERRED  TO, 


713 


Schlessing,  346. 

Schmidt,  155,  156,  451,  569,  578. 
Schmucker,  227. 

Schneider,  156. 

Schreger,  244,  251,  255. 

Schultz,  76. 

Schulzius,  245. 

Schwann,  460. 

Schweighauser,  155,  156. 

Schwilgai,  662. 

Scudamore,  429,  430. 

Scultetus,  65,  452. 

Sedillot,  220,  262. 

Segalas,  101. 

Segard,  404. 

Segrot,  168. 

Seguin,  204. 

Seneca,  542. 

Sennerlus,  93,  196,491,  495,  496,519,  531, 
532. 

Serres,  45. 

Seymour,  411,  415,  421,  428,  429,  430. 
Sibergundi,  158. 

Siebold,  363,  405,  409,  453. 

Sigaud  Lafond,  476,  512. 

Simmons,  228. 

Simpson,  25,  391. 

Sims,  201. 

Simson,  113,  386,  645. 

Sinibaldus,  78. 

Smellie,  32,  157,  158,  206,  280,  281,595, 
633. 

Smith,  A.  G.,  417. 

, N.,  417. 

Soemmering,  381,  385,  456. 

Soby,  514. 

Solenander,  368. 

Solingen,  88,  577,  584. 

Solly,  655. 

Solon,  M.,  412. 

Sonnini,  80. 

Soranus,  88, 121,  152,  198,  513,  514,  519. 
Sorbait,  77. 

Southam,  416,  417. 

Spachius,  65,  154,  386. 

Sparjani,  493. 

Sparmann,  44. 

Spaering,  580. 

Stahl,  25,  320,  476,  487,  520. 

Stark,  580. 

Stein,  198. 

Steelier,  385. 

Stilling,  417. 

St.  Maurice,  57 5. 

Stoll,  492,  586,  696. 

Stoltz,  107,  108,  112,  113,  118,  287,  288, 
370,  477. 

Storck,  322,  451. 

Strambio,  422. 

Strother,  654. 

Sue,  227. 

Suidas,  82,  431. 

Sultzer,  451. 

Sunot,  477, 


Suret,  143. 

Swammerdam,  381. 

Swenck,  516,  note. 

Sydenham,  318,  492,  495,  512,  514,  519, 
524,  529,  533. 

Sylvius,  25,  309,  529. 

Syme,  155,  158,  164,  167. 

Tackard,  44. 

Tagault,  452. 

Talenta,  J.  V.  de,  370. 

Tanqueret  des  Planches,  496. 

Taranta,  367,  370. 

Tarral,  365. 

Taveau,  557. 

Teallier,  333,  335,  339,  344. 

Theden,  54,  401,  429. 

Then-Rhine,  44. 

Thevenot,  80. 

Thibert,  471. 

Thiebault,  453,  456. 

Thompson,  65. 

Thoumain,  395. 

Thouret,  524, 

Thuillier,  453,  456. 

Tiedemann,  59,  521. 

Timaeus,  451. 

Tissot,  495,  496,  519,  529,  540,  561. 

Toilet,  Fr.,  203. 

Tonnele,  662. 

Toulmouche,  113. 

Tourtelle,  487. 

Trainel,  220. 

Trallianus,  293,  400. 

Treviranus,  580. 

Triller,  452,  553. 

Trolliet,  536. 

Tronchin,  559. 

Trousseau,  270,  271,  476,  493,  496,  537, 
Tulpius,  346,  406. 

Turnbull,  578,  580. 

Turnebus,  Adrian,  198. 

Ulmanst,  342. 

Vacher,  305,  447,  453. 

Valerius  Maximus,  561. 

Valescus,  de  Tarenta,  38,  451. 

Vallerand,  575,  580. 

Vallisnieri,  54,  381. 

Valsalva,  91,  339. 

Vander  Bosch,  487. 

Vanderhaar,  431. 

Vandoeveren,  158. 

Vanderwiel,  213,  234,  571. 

Vandeusande,  661. 

Vanhelmont,  24,  42,  59,  512. 

Vanswieten,  280,  313,  381,  529,  660 
Varande,  495,  518. 

Vargas,  21. 

Varoquier,  575. 

Vater,  406. 

Vauguyon,  452. 

Vaulre,  538. 


714 


INDEX  OF  AUTHORS  REFERRED  TO. 


Vedekin,  494.  i Walter,  Wall,  154,  155. 

Veidmann,  191.  j Walther,  381. 

Velpeau,  52,  67,  112,  214,  249,  258,  259,  Warner,  J.  S.,  141. 

262,  263,  321,  355,  381,  409,453,  455,  Warrington,  183. 

478.  571,  575,  583,  589,  611,  640,  642,  Weikard.  310.  654. 


654,  661,  683. 

Velter,  434. 

Ventusa,  113. 

Verheyen,  31,  580. 

Verdier,  198,  199,  205. 

Verduc,  452,  453. 

Vesalius,  375,  451,  519,  529. 
Veslingius,  226. 

Viardel  91. 

Vidal  di  Cassis,  220,  260,  261,  272. 
Vieussens,  575. 

Vigarous,  178,  519,  654. 

Vigny,  341. 

Villars,  Caron  du,  322. 

Villeneuve,  409. 

Villerme,  143. 

Villette,  92. 

Virey,  546. 

Viricel,  of  Lyons,  167. 

Virgil,  113. 

Viridet,  519. 

Vogel,  520,  536. 

Voigtel,  157. 

Voisin,  112,  518. 

Wagner,  127,  128,  150,  460. 
Waille,  107,  116. 

Waller,  370. 

Walne,  417,  418. 

Walter,  59,  249,  385. 


Weinhard.  578,  584. 

Weinknecht,  578. 

Weinrien,  of  Breslau,  571.  1 

Wepfer,  422. 
i WerlhofF,  24. 

West,  417,  477. 

Wharton,  28,  460. 

White,  655. 

Why tt,  519,  529. 

Widman,  211,  215. 

Wierus,  88,  431. 

Willaume,  113,  477. 

Willis,  91,  428,  514,  419,  423,  536,  540. 
654,  659. 

| Wilson,  270,  575,  662. 

I Windsor,  152,  153,  189. 
j Wirer,  377. 

Wizezech,  155. 

} Wlesling,  80. 

| Wrisberg,  189,  346. 

[ Young,  448. 

Zacchias,  30,  82,  118. 

! Zacutus  Lucitanus,  408,  519. 

Zang,  377,  541,  453,  455,  456. 

Zeller,  143,  453. 
j Ziegert,  487. 

Zimmermann,  82. 


INDEX 


OF 

DISEASES  OE  FEMALES. 


Abscess  of  the  ovarium,  vide  Ovarium 

of  the  womb,  vide  Uterus 

Abortion,  585 

causes,  586 
symptoms,  588 
prognosis,  591 
treatment,  591 
cases,  587,  589 

After-pains  succeeding  delivery,  649 
treatment,  650 
Agalactia,  688 

treatment,  689 
Agrypnia,  or  insomnia,  628 
treatment,  628 
Amenorrhoea,  463 
causes,  463 
symptoms,  466 
diagnosis,  470 
prognosis,  473 
treatment,  473 
Anorexia,  599 

treatment,  599 

Anteversion  of  the  womb,  vide  Uterus 
Anteflexion  of  the  womb,  vide  Uterus 
Atresia  of  the  Fallopian  tubes,  vide  Fallo- 
pian Tubes 

Boulimia,  599 

treatment,  600 

Calculi  of  the  Womb,  381 
causes,  382 
treatment,  384 
Cancer  of  the  uterus,  328 
varieties,  328 
causes,  331 
symptoms,  333 
diagnosis,  336 
prognosis,  337 
treatment,  338 
extirpation  of,  360 

of  the  breast,  441 

causes,  441 
symptoms,  442 


Cancer,  diagnosis  of,  446 
prognosis,  446 
treatment,  447 
case,  444 

of  the  ovarium,  433 

causes,  434 
symptoms,  434 
diagnosis,  435 
prognosis,  435 
treatment,  436 

of  the  vagina,  437 

treatment,  438 
Cephalalgia,  627 

varieties,  627 
treatment,  627 

Cervix  uteri,  occlusion  of,  113 
remedy,  114 
Chlorosis,  495 

causes,  499 
symptoms,  500 
diagnosis,  503 
prognosis,  507 
treatment,  507 
Chronic  metritis,  293 

without  engorgement, 294 

with  engorgement,  295 

Clitoris,  unnatural  development  of,  82 
cases,  83 
excision  of,  83 

Compression,  in  case  of  cancer  in  the 
breast,  vide  Cancer 
Constipation,  604 

treatment,  605 

Contusions  of  the  vagina,  vide  Vagina 

of  the  mammae,  vide  Mammae 

Convulsions,  puerperal,  vide  Eclampsia 
Cough,  609 

varieties,  609 
treatment,  610 

Cystocele,  vaginal,  vide  Hernia 

Dropsy  of  the  womb,  vide  Hydrometra 

of  the  ovarium,  vide  Ovarium 

Diarrhoea,  605 


716 


INDEX  OF  DISEASES  OF  FEMALES. 


Diarrhoea,  treatment  of,  606 
Dysentery,  605 

treatment,  606 
Dysmenorrhoea,  479 
causes,  479 
symptoms,  479 
treatment,  480 
Dyspepsia,  600 

prognosis,  600 
treatment,  600 
Dysphagia,  601 

treatment,  602 
Dyspnoea,  606 
case,  607 
treatment,  607 

Eclampsia,  632 

causes,  633 
symptoms,  635 
treatment,  639 

Encysted  tumours  of  the  vulva,  440 

labia  majora,  439 

treatment,  440 

mammae,  457 

varieties,  458 
treatment,  458 

Engorgement,  chronic  metritis,  without, 
294;  with,  295 

of  the  uterus,  297 

treatment,  298 

with  haemor- 
rhage, 30 1 

treatment,  302 

with  indura- 
tion, 363 

. treatment,  304 

scirrhous,  305 

symptoms,  304 
treatment,  305 

uterine,  476 

treatment,  476 
Enteralgia,  604 

treatment,  604 

Extirpation  of  cancerous  uterus,  360 
Sauter’s  method,  362 
Recamier’s,  364 
Tarral  and  Gendrin,  365 
Dubled’s,  365 

of  the  ovary,  vide  Ovary 

Fallopian  Tubes,  atresia  of,  115 

inflammation  of,  410 

causes,  410 
symptoms,  410 
diagnosis,  413 
prognosis,  413 
treatment,  414 
case,  412 

dropsy  of,  420 

causes,  423 
symptoms,  423 
treatment,  428 
Fever,  milk,  652 
puerperal,  vide  Peritonitis 


| Fistula,  vesico-vaginal,  238 

treatment,  palliative  method,  243 
tamponnement,  245 
cauterization,  246 
the  suture,  249 
the  author’s  method,  252 
Lallemand’s,  257 
Dupuytren’s,  258 
Laugier’s,  258 
Recamier’s,  259 
Jobert  de  Lamballe’s,  260 
Vidal’s,  260 

recto- vaginal,  261 

cases,  262,  263,  264 
treatment,  263 

Dr.  J.  Rhea  Barton’s  method, 
264 

Furor  uterinus,  vide  Nymphomania 

Gangrenous  Inflammation  of  the  Labia 
Majora,  273 
Gastralgia,  602 

treatment,  603 
Gastro-intestinal  spasm,  538 
causes,  539 
varieties,  539 
treatment,  540 

Heartburn, 602 

treatment,  602 
Hernia,  uterine,  194 

1.  Inguinal 
cases,  194, 195 

2.  Crural 
cases,  195,  196 

3.  Ventral 
case,  197 
treatment,  197 

ovarian,  vide  Ovarium 

— of  bladder  in  the  vagina,  201 

causes,  201 
cases,  202 
treatment,  203 

vaginal,  205 

causes,  205 
treatment,  206 
case,  207 

vulvar,  208 

treatment,  209 
Haemoptysis,  616 

prognosis,  617 
treatment,  617 
Haemorrhage,  uterine,  483 
varieties,  486 
causes,  487 
diagnosis,  489 
prognosis,  490 
treatment,  490 

during  pregnancy,  610 

treatment,  613 
Haemorrhoids,  624 

treatment,  625 
Hydatids  of  the  womb,  378 
causes,  779 


IftDEX  OF  DISEASES  OF  FEMALES. 


717 


Hydatids,  diagnosis  of,  379 
treatment,  380 

Hydrometra,  374 
causes,  374 
symptoms,  375 
diagnosis,  375 
prognosis,  376 
treatment,  377 

Hypersemia  of  the  womb,  vide  Uterus. 

Hysteralgia,  540 

symptoms,  541 
treatment,  541 

Hysteria,  and  other  spasmodic  diseases, 
518 

causes,  523 
symptoms,  524 
treatment,  532 

Hysteriform  attacks,  536 
causes,  537 
symptoms,  528 
treatment,  541 

Hysterocele  of  the  womb,  194 
inguinal,  195 
crural,  195 
ventral,  196 
treatment,  197 

Hysterotomy,  351 

cases,  353,  354,  355 
author’s  method,  356 
after-treatment,  358 

Hygienic  rules  in  relation  to  Puberty,  542 
Menstruation,  545 
Union  of  the  sexes,  546 
Change  of  life,  549 

Hygiene  of  women,  552 

1.  Circumfusa,  552 

2.  Applicata,  554 

3.  Ingesta,  558 

4.  Excreta,  559 

5.  Gesta,  559 

6.  Percepta,  561 

of  pregnant  and  lying-in  women, 

696 

bathing  and  blood-letting,  697 
diet,  evacuations,  exercise,  698 
violent  mental  impressions,  699 
labour,  700 

Impotence  and  Sterility,  562 
causes,  563 
treatment,  566 

Immobility  of  the  womb,  vide  Uterus 

Inclination,  or  obliquity  of  the  womb, 
vide  Uterus 

Inertia  of  the  womb,  685 
causes,  685 
treatment,  686 

Inflammation,  acute,  of  the  vagina,  vide 
Vagina 

of  the  uterus,  vide  Uterus 
of  the  ovaria,  vide  Ovaria 
of  the  Fallopian  tubes,  vide  Fallopian 
Tubes 

of  the  mammae,  vide  Mammae 


Inversion  of  the  womb,  vide  Uterus 
Insomnia,  628 

treatment,  628 
Invagination  of  vagina,  214 
Inversion  of  vaginal  mucous  membrane, 
209 

causes,  210 
symptoms,  210 
prognosis,  21 1 
treatment,  212 

Jaundice,  506 

Labia  Majora,  union  of,  76 
case,  76 
treatment,  78 
contusion  of,  216 
treatment,  216 
phlegmon  of,  272 
gangrenous  inflammation  of,  273 
treatment,  273 

Lactation,  lesions  relative  to,  688 
polygalactia,  689 
galactirrhcea,  689 
alterations  of  the  milk,  691 
Leucorrhoea,  307 
causes,  308 
acute,  310 
subacute,  311 
passive  chronic,  311 
prognosis,  316 
treatment,  320 
Lochia,  651 

treatment,  651 

Malacia,  600 

treatment,  601 
Mammae,  diseases  of,  692 
treatment,  692 
inflammation  of,  693 
symptoms,  693 
prognosis,  694 
treatment,  694 

contusions  and  wounds  of,  229 
treatment,  230 
Menstruation,  22 

commencement  of,  23 
derangements,  459 
immoderate  flow  during  pregnancy, 
483 

cessation,  37 
absence  of,  30 
case,  30 

hygienic  rules  concerning,  542 
Metritis,  puerperal,  277 
treatment  of,  284 
acute,  284 

treatment  of,  284 
chronic,  293 

with  engorgement,  295 
Metrorrhagia,  486 
essential,  486 
sympathetic,  487 
symptomatic,  493 


718 


INDEX  OF  DISEASES  OF  FEMALES. 


Metrorrhagia,  treatment  of,  493 
Metrorrhage,  610 

treatment,  611 
Milk-fever,  652 

symptoms,  652 
treatment,  653 
Miliary  eruptions,  687 
treatment,  688 
Moles,  570 

causes,  572 
diagnosis,  572 
treatment,  573 

Nausea  and  Vomiting,  595 
treatment,  596 
Neuritis,  puerperal,  6S4 
treatment,  684 
Neuroses,  ocular,  629 
treatment,  629 
cases,  630 

Nymphas,  cohesion  of,  79 
cases,  79 
remedy,  80 

excessive  development  of,  80 
excision  of,  82 
case,  83 

Nymphomania,  513 
causes,  515 
symptoms,  515 
treatment,  516 

(Edema  of  the  Vulva,  438 
treatment,  439 
of  pregnant  women,  625 
treatment,  626 
painful,  682 
treatment,  684 
Odontalgia,  598 

treatment,  598 

Os  tincae,  eruptions  upon,  323 
treatment,  324 

chancres,  325 

treatment,  326 

scrofulous  ulcers,  325 

treatment,  326 

Ovaria,  inflammation  of,  410 
causes,  410 
symptoms,  410 
diagnosis,  413 
prognosis,  413 
treatment,  414 
case,  412 

Ovarium,  hernia  of,  198 
causes,  199 
treatment,  200 

dropsy  of,  420 

varieties,  421 
causes,  423 
symptoms,  423 
diagnosis,  425 
prognosis,  427 
treatment,  428 

extirpation  of,  417 

cases,  417 


Palpitation, 619 
causes,  619 
treatment,  619 
case,  620 

Perineum,  rupture  of,  217 
treatment,  217 
cases,  219,  221,  223 
Peritonitis,  puerperal,  654 
causes,  654 
symptoms,  655 
diagnosis,  658 
prognosis,  658 
treatment,  659 

Pessaries  in  prolapsus  uteri,  133 
uses  of,  150,  151 
j Phlebitis,  uterine,  661 
symptoms,  662 
treatment,  664 

other  kinds  of  puerperal  phlebitis,  665 
Plethora,  sanguine,  618 
symptoms,  618 
treatment,  619 

' Physometra  of  the  womb,  366 
causes,  366 
case,  369 
symptoms,  370 
prognosis,  373 
treatment,  373 
Polygalactia,  689 

treatment,  690 
Polypus  of  the  womb,  385 
varieties,  386 
causes,  392 
symptoms,  392 
prognosis,  399 
treatment,  400 
Dessault’s  instruments,  401 
Dupuytren’s  operation,  406 
Pregnancy,  false,  568 
symptoms,  569 
treatment,  569 

extra-uterine,  574 

cases,  577 
signs,  579 
treatment,  582 
Prurigo  of  the  vulva,  269 
symptoms,  270 
treatment,  271 

Puncture  in  ovarian  abscess,  167 
Pyrosis,  601 

causes,  601 
treatment,  602 

Recto-vaginal  Fistula,  vide  Fistula 
Retroflexion  of  the  womb,  vide  Uterus 
Retroversion  of  the  womb,  vide  Uterus 
Rheumatism  of  the  womb,  286 
causes,  287 
symptoms,  287 
prognosis,  292 
treatment,  293 
Rupture  of  vagina,  224 
treatment,  225 
I of  uterus,  230 


INDEX  OF  DISEASES  OF  FEMALES. 


719 


Rupture  of  uterus,  cases  of,  231 
treatment,  236 

Scirrhous  Engorgement  of  the  Womb, 
vide  Uterus 

Sight,  lesions  of,  vide  Neuroses 
Speculum  uteri,  manner  of  using  it,  64 
Superficial  inflammation  of  the  vulva,  vide 
Vulva 

Syncope,  621 

causes,  622 
treatment,  622 

Tenesmus,  605 

treatment,  606 
Touching  per  vaginam,  60 
by  the  rectum,  62 
at  the  hypogastrium,  63 
Tubercular  induration  of  uterus,  305 
treatment,  306 

Tympanitis  of  the  womb,  vide  Physometra 

Urethra,  imperforation  of,  85 
case,  86 
remedy,  87 

Urinary  organs,  disorders  of,  647 
remedies,  648 
Uterine  haemorrhage,  610 
Uterine  phlebitis,  661 
symptoms,  662 
diagnosis,  663 
prognosis,  663 
treatment,  664 
cases,  679,  681 

Varix  of  the  Vulva,  439 
causes,  439 
treatment,  439 
Varices,  622 

causes,  623 
treatment,  623 
Vagina,  absence  of,  116 
case,  116 
remedy,  ] 17 
imperforation,  87 
cases,  91,  92 
remedy,  90 
narrowness,  94 
case,  95 


Vagina,  narrowness,  remedy  for,  96 
obliteration,  100 
cases,  101,  102 
remedy,  105 
obturation,  106 
cases,  107,  108 
remedy,  111 
hernia  in,  vide  Hernia 
rupture  of,  vide  Rupture 
foreign  bodies  introduced  into,  266 
cases,  267,  268 
cancer  of,  vide  Cancer 
Vertigo,  vide  Cephalalgia 
Vesico-vaginal  fistulas,  vide  Fistulas 
Vulva,  superficial  inflammation  of,  269 
prurigo  of,  269 
treatment  of,  270 
acute  inflammation  of,  274 
treatment  of,  275 

oedema,  varix,  and  other  tumours  of, 
438 

treatment,  439 
Vulvar  enterocele,  208 
cystocele,  208 

Uterus,  prolapse  of,  122 
symptoms,  123 
case,  126 
causes,  128 
treatment,  129 
ante  version  of,  154 
symptoms,  156 
retroversion  of,  154 
symptoms,  154 
treatment,  163 
anteflexion  of,  169 
retroflexion  of,  170 
treatment,  171 
inversion  of,  175 
symptoms,  179 
treatment,  185 
cases,  182,  183 
rupture  of,  vide  Rupture 
acute  inflammation  of,  277 
causes,  277 
symptoms,  278 
diagnosis,  282 
prognosis,  283 
treatment,  284 


THE  END. 


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Sixth  edition,  greatly  improved. — In  two  large  octavo  volumes,  containing  nearly  1350  pages. 

“ It  is  but  necessary  for  the  Author  to  say,  that  all  the  cares  that  were  bestowed  on  the  preparation 
of  the  fifth  edition  have  been  extended  to  the  sixth,  and  even  to  a greater  amount.  Nothing  of  import- 
ance that  has  been  recorded  since  its  publication,  has,  he  believes,  escaped  his  attention.  Upwards 
of  seventy  illustrations  have  been  added  ; and  many  of  the  former  cuts  have  been  replaced  by  others. 
The  work,  he  trusts,  will  be  found  entirely  on  a level  with  the  existing  advanced  stale  of  physiological 
science.” 

In  mechanical  and  artistical  execution,  this  edition  is  far  in  advance  of  any  former 
one.  The  illustrations  have  been  subjected  to  a thorough  revision,  many  have  been 
rejected  and  their  places  supplied  wilh  superior  ones,  while  numerous  new  wood- 
cuts have  been  added  wherever  perspicuity  or  novelty  seemed  to  require  them. 

“Those  who  have  been  accustomed  to  consult  the  former  editions  of  this  work,  know  with  how 
much  care  and  accuracy  every  fact  and  opinion  of  weight,  on  the  various  subjects  embraced  in  a 
treatise  on  Physiology,  are  collected  and  arranged,  so  as  to  present  the  latest  and  best  account  of  the 
science.  To  such  vve  need  hardly  say,  that,  in  this  respect,  the  present  edition  is  not  less  distinguished 
than  those  which  have  preceded  it.  in  the  two  years  and  a half  wdiich  have  elapsed  since  the  last  or 
fifth  edition  appeared,  nothing  of  consequence  that  has  been  recorded  seems  to  have  been  omitted. 
Upwards  of  seventy  illustrations  have  been  added,  and  many  of  the  former  cuts  have  been  replaced 
by  others  of  better  execution.  These  mostly  represent  the  minute  structures  as  seen  through  the 
microscope,  and  are  necessary  for  a proper  comprehension  of  the  modern  discoveries  in  this  depart- 
ment.— The  Medical  Examiner. 


NOW  READY. 

THE  SIXTH  EDITION  OF  DIINGLISON’S  MEDICAL  DICTIONARY. 

MEDICA  L_L  EZIGOrr. 

A Dictionary  of 

MEDICAL  SCIENCE, 

CONTAINING  A CONCISE  ACCOUNT  OF  THE  VARIOUS  SUBJECTS  AND  TERMS:  WITH 
THE  FRENCH  AND  OTHER  SYNONYMES;  NO  HOES  OF  CLIMATES  AND  OF 
CELEBRATED  MINERAL  WATERS;  FORMULAE  FOR  VARIOUS  OFFICI- 
NAL AND  EMPIRICAL  PREPARATIONS,  &c. 

BY  ROBLEY  DUNGLISON,  M.  D., 

PROFESSOR  OF  THE  INSTITUTES  OF  MEDICINE,  ETC.,  IN  JEFFERSON  MEDICAL  COLLEGE,  PHILADELPHIA. 

Sixth  edition,  revised  and  greatly  enlarged.  In  one  royal  octavo  volume  of  over  800  very  large 
pages,  double  columns.  Strongly  bound  in  the  best  leather,  raised  bands. 

“ We  think  that  ‘the  author’s  anxious  wish  to  render  the  work  a satisfactory  and  desirable — if  not 
indispensable — Lexicon,  in  which  the  student  may  search  without  disappointment  for  every  terra 
that  has  been  legitimated  in  the  nomenclature  of  the  science,’  has  been  fully  accomplished.  Such  a 
work  is  much  needed  by  all  medical  students  and  young  physicians,  and  will  doubtless  continue  in 
extensive  demand.  It  is  a lasting  monument  of  the  industry  and  literary  attainments  of  the  author, 
wrho  has  long  occupied  the  highest  rank  among  the  medical  teachers  of  America.”—  The  New  Orleans 
Medical  and  Surgical  Journal. 

“ The  simple  announcement  of  the  fact  that  Dr.  Dunglison’s  Dictionary  has  reached  a sixth  edition, 
is  almost  as  high  praise  as  could  be  bestowed  upon  it  by  an  elaborate  notice.  It  is  one  of  those  standard 
works  that  have  been  ' w’eighed  in  the  balance  and  (not)  been  found  weanling.  ’ It  lias  stood  the  test  of 
experience,  and  the  frequent  calls  for  new  editions,  prove  conclusively  that  it  is  held  by  the  profession 
and  by  students  in  the  highest  estimation.  The  present  edition  is  not  a mere  reprint  of  former  ones; 
the  author  has  for  some  time  been  laboriously  engaged  in  revising  and  making  such  alterations  and 
additions  as  are  required  by  the  rapid  progress  of  our  science,  and  the  introduction  of  new  terms  into 
out  vocabulary.  In  proof  of  this  it  is  stated  ‘ that  the  present  edition  comprises  nearly  two  thousand 
five  hundred  subjects  and  terms  not  contained  in  the  last.  Many  of  these  had  been  introduced  into 
medical  terminology  in  consequence  of  the  progress  of  the  science,  and  others  had  escaped  notice  in 
previous  revisions.’  We  think  that  the  earnest  w’ish  of  the  author  has  been  accomplished;  and  that 
ne  has  succeeded  in  rendering  the  work  ‘a  satisfactory  and  desirable— if  not  indispensable— Lexicon, 
in  which  the  student  may  search,  without  disappointment,  for  every  term  that  has  been  legitimated  in 
the  nomenclature  of  the  science.’  This  desideratum  he  has  been  enabled  to  attempt  in  successive 
editions,  by  reason  of  the  work  not  being  stereotyped ; and  the  present  edition  certainly  offers  stronger 
claims  to  the  attention  of  the  practitioner  and  student,  than  any  of  its  predecessors.  The  work  is  got 
up  in  the  usual  good  taste  of  the  publishers,  and  we  recommend  it  in  full  confidence  to  all  who  have 
not  yet  supplied  themselves  wilh  so  indispensable  an  addition  to  their  libraries.”—  The  New  York  Jour- 
nal of  Medicine. 


NEW  WORKS  AND  NEW  EDITIONS  LATELY  PUBLISHED  BY  LEA  AND  BLANCHARD.  5 


Now  Ready,  — Carpenter’s  New  Work. 


A MANUAL,  OR  ELEMENTS  OF  FmrSZOZiGGHT, 
IJVCJL  UJ&IJTG  FMJT  SIOI.®aiCJlL  JV  Jl  T O JfS  Y , 

FOR  THE  USE  OF  THE  MEDICAL  STUDENT. 

BY  WILLIAM  B.  CARPENTER,  M.  D.,  F.  R.  S., 

FULLERIAN  PROFESSOR  OF  PHYSIOLOGY  IN  THE  ROYAL  INSTITUTION  OF  GREAT  BRITAIN,  ETC., 

With  one  hundred  and  eighty  illustrations.  In  one  octavo  volume  of  566  pages.  Elegantly  printed 
to  match  his  “ Principles  of  Human  Physiology.” 

This  work,  though  but  a very  short  time  published,  has  attracted  much  attention  from  all  engaged 
in  teaching  the  science  of  medicine,  and  has  been  adopted  as  a text  book  by  many  schools  throughout 
the  country.  The  clearness  and  conciseness  with  which  all  the  latest  investigations  are  enunciated 
render  ii  peculiarly  well  suited  for  those  commencing  the  study  of  medicine.  It  is  profusely  illustrated 
with  beautiful  wood  engravings,  and  is  confidently  presented  as  among  the  best  elementary  text 
books  on  Physiology  in  the  language. 

“The  author  has  shown  singular  skill  in  preserving  so  marked  a line  of  distinction  between  the 
present  Manual  and  the  ‘ Principles  of  Physiology’  previously  published  by  him.  They  are  both  on 
precisely  the  same  subject;  but  the  one  is  neither  a copy,  nor  an  abstract,  nor  an  abridgment  of  the 
other.  In  one  thing,  however,  they  are  exactly  alike— in  their  general  excellence,  and  in  their  per- 
fect  adaptation  to  their  respective  purposes.  The  reputation  of  Dr.  Carpenter  as  a physiologist  is  too 
well  established  throughout  the  whole  medical  world  to  admit  of  increase  from  any  commendation  of 
ours;  but  we  should  be  doing  injustice  to  our  own  feelings  if  we  did  not  here  express  our  admiration 
of  his  great  intellectual  powers,  of  his  extensive  learning,  of  the  comprehensiveness  of  his  views,  of 
the  quickness  with  which  he  seizes  the  important  points  and  bearings  of  each  subject,  of  the  logical 
order  in  which  he  arranges  his  facts,  and  of  the  clearness  and  precision  with  which  he  explains  and 
exposes  his  doctrines.  Dr.  Cavpenter’s  various  treatises  are  in  fact  models  in  their  respective  depart- 
ments. It  is  their  great  and  varied  excellence  which  accounts  for  their  unrivalled  popularity.  We 
can  pay  no  higher  compliment  to  the  work  before  us,  than  to  say,  that  it  is  equal  in  merit  to  the  former 
productions  of  the  author.  This  is  equivalent  to  saying  that  it  is,  without  question,  the  best  manual  or 
short  treatise  on  physiology  extant.  Although  designed  for  the  student,  and  framed  expressly  to  meet 
his  wants,  it  is  a work,  we  will  venture  to  say,  that  may  be  consulted  with  advantage  by  most  physi- 
cians and  surgeons,  however  learned.”— The  British  and  Foreign  Medical  Review. 

The  merits  of  this  work  are  of  such  a high  order,  and  ils  arrangement  and  discussion  of  subjects  so 
admirably  adapted  to  the  want  of  students,  that  we  unhesitatingly  commend  it  to  their  favorable  no- 
tice. This  work  studied  first,  and  then  followed  by  the  more  elaborate  treatise  of  Dunglison.  or  Muller, 
or  others  of  similar  character,  is  decidedly  the  best  course  for  the  student  of  physiology.” — The  Western 
Lancet. 


Simon’s  Chemistry  of  W£an. 


ANIMAL  CHEMISTRY. 

WITH  REFERENCE  TO  THE  PHYSIOLOGY  AND  PATHOLOGY  OF  MAN. 

BY  Dr.  J.  FRANZ  SIMON. 

Translated  and  edited  by  George  E.  Day,  M.  A.  & L.  M.,  Cantab.,  &c. 

With  plates.  In  one  octavo  volume  of  over  seven  hundred  pages,  sheep,  or  in  two  parts  boards. 

This  important  work  is  now  complete  and  may  be  had  in  one  large  octavo  volume,  Those  who 
obtained  the  first  part  can  procure  the  second  separate.  The  very  low 'price  at  which  this  is  offered, 
in  comparison  with  the  cost  of  the  English  edition,  should  secure  for  it  a large  demand. 

“Phis  excellent  work,  the  most  complete  on  animal  chemistry  that  has  ever  appeared,  has  recently 
been  issued  by  the  publishing  house  of  Lea  and  Blanchard,  after  the  Sydenham  edition  of  London.  No 
physician,  who  desires  to  keep  pace  with  the  improvements  in  our  science,  or  to  be  prepared  at  all 
points  for  the  successful  treatment  of  disease,  can  remain  ignorant  of  physiological  and  pathological 
chemistry ; and  he  will  seek  in  vain  for  as  complete  and  accurate  work  on  the  subject,  as  he  will  find 
in  the  elaborate  and  finished  treatise  of  Dr.  Simon  The  work  is  replete  with  facts  of  the  highest  interest, 
calculated  to  reflect  a broad  blaze  of  tight  on  the  pathology  and  treatment  of  many  diseases  hitherto 
involved  in  obscurity.  We  trust  it  may  have  a universal  circulation  among  the  profession  in  this 
country. — The  New  York  Journal  of  Medicine. 


Now  Ready— A New  Edition  of 

COMDIE  O N CHILDREN. 

BROUGHT  UP  TO  1847. 

In  one  octavo  volume  of  over  650  pages. 


6 NEW  WORKS  AND  NEW  EDITIONS  LATELY  PUBLISHED  BY  LEA  AND  BLANCHARD.  ’ 


A NEW  EDITION— JUST  READY. 

Dunglison  on  Mew  Remedies. 

JVE  !»’  REMEDIES, 

BY  ROBLEY  DUNGLISON,  M.D.,  &c.,  &c. 

Fifth  edition,  with  extensive  additions.  In  one  neat  octavo  volume. 

The  numerous  valuable  therapeutical  agents  which  have  of  late  years  been  introduced  into  the 
Materia  Medica,  render  it  a difficult  matter  for  the  practitioner  to  keep  up  with  the  advancement  of 
the  science,  especially  as  the  descriptions  of  them  are  difficult  of  access,  being  scattered  so  widely 
through  transactions  of  learned  societies,  journals,  monographs,  See.  & c.  To  obviate  this  difficulty, 
and  to  place  within  reach  of  the  profession  this  important  information  in  a compendious  form,  is  the 
object  of  the  present  volume,  and  the  number  of  editions  through  which  it  has  passed  show  that  its 
utility  has  not  been  underrated. 

The  author  has  taken  particular  care  that  this  edition  shall  be  completely  brought  up  to  the  present 
day.  The  therapeutical  agents  added,  which  may  be  regarded  as  newly  introduced  into  the  Materia 
Medica,  together  with  old  agents  brought  forward  with  novel  applications,  and  which  may  therefore 
be  esteemed  as  “New  Remedies,”  are  the  following Benzoic  Acid,  Chromic  Acid,  Gallic  Acid,  Nitric 
Acid,  Phosphate  of  Ammonia,  Binelli  Water,  Brocchieri  Water,  Atropia.  Beerberia,  Chloride  of  Car- 
bon (Chloroform,)  Digitalia,  Electro-Magnetism,  Ergotin,  Ox-gall,  Glycerin,  Haemospasy,  Haemostasis, 
Hagenia  Abyssinica,  Honey  Bee,  Protochloride  of  Mercury  and  Quinia,  Iodoform,  Carbonate  of  Lithia, 
Sulphate  of  Manganese,  Matico,  Double  Iodide  of  Mercury  and  Morphia,  Iodhydrate  of  Morphia, 
Iodide  of  Iodhydrate  of  Morphia,  Muriate  of  Morphia  and  Codeia,  Naphthalin,  Piscidia  Erythrina, 
Chloride  of  Lead,  Nitrate  of  Potassa,  Arseniate  of  Quinia,  Iodide  of  Quinia,  Iodide  of  Cinchonia, 
Iodide  of  Iodhydrate  of  Quinia,  Lactate  of  Quinia,  Pyroacetic  Acid,  (Naphtha,  Acetone)  Hyposulphate 
of  Soda,  Phosphate  of  Soda,  Iodide  of  Iodhydrate  of  Stryrchnia,  Double  Iodide  of  Zinc  and  Strychnia, 
Double  Iodide  of  Zinc  and  Morphia,  and  Valerianate  of  Zinc. 


Massed  Pathological  Anatomy. 


AN  ANATOMICAL  DESCRIPTION  OF  THE  DISEASES  OF  THE 

ORGANS  OF  CIRCULATION  AND  RESPIRATION. 

BY  CHARLES  EWALD  HASSE, 

Professor  of  Pathology  and  Clinical  Medicine  in  the  University  of  Zurich , <$-c. 

Translated  and  edited  by  W.  E.  Swaine,  M.  D.,  &c. 

In  one  octavo  volume.  A new  work,  just  ready, — October,  1846. 

••  The  advantages  which  Professor  Hasse  has  possessed  for  the  preparation  of  such  a work  as  the 
present,  appear  to  have  been  considerable,  and  of  these  he  has  manifestly  availed  himself  to  the 
utmost.  As  a diligent  student  in  the  hospitals  of  Paris  and  Vienna,  and  subsequently  as  clinical 
assistant  to  Professor  Carus,  and  pathological  prosector  in  the  principal  hospital  at  Leipsic,  he  pos- 
sessed the  means  of  observing  and  collecting  materials  for  himself,  whilst  at  the  same  time  he  was 
forming  that  ‘ pathological  collection,’  which,  under  his  auspices,  has  grown  into  a most  interesting 
and  valuable  museum.  The  present  treatise,  therefore,  differs  essentially  from  what  is  commonly 
called  a compilation.  For  although  he  has  ‘not  relied  solely  on  his  own  investigations,  but  has 
largely  availed  himself  of  facts  recorded  by  others,’  he  has  been  chary  in  making  use  of  other  men’s 
experience.  The  estimation  in  which  the  book  is  held  in  Germany,  is  sufficiently  attested  by  the  fact 
that  since  its  publication  the  author  has  had  the  offer  of  the  chair  of  Clinical  Medicine  in  five  Universi- 
ties, and  holds  that  vacated  by  Professor  Schoenlein,  at  Zurich.” — The  Medico-  Ckirurgical  Review. 


A NEW  WORK.— PHILLIPS  ON  SCROFULA.— JUST  READY. 


TS  NATURE,  ITS 


l(D  3R  (Q)  IF  W 3Li  A 

PREVALENCE,  ITS  CAUSES, 
PLES  OF  ITS  TREATMENT. 


AND  THE  P RINCI 


BY  BENJAMIN  PHILLIPS,  M.D.,  F.  R.  S.,  ETC. 

In  one  neat  octavo  volume,  with  a plate. 

•The  work  of  Mr.  Phillips  is  immensely  in  advance  of  all  others  that  have  ever  been  written  on 
Scrofula. 

“The  author  has  extended  his  researches  over  a wide  and  most  interesting  field.  It  has  been  a 
fault  with  preceding  writers,  that  they  have  not  enjoyed  a very  extensive  sphere  of  observation,  or 
extended  their  inquiries  so  as  to  comprise  the  influence  of  the  many  causes  which  are  supposed  to  be 
capable  of  producing  the  disease. 

‘•He  has  even  extended  his  inquiries  to  Russia,  Austria,  Prussia,  Bavaria,  Portugal,  Holland, 
France,  Switzerland,  Belgium  and  America,  to  China  and  the  East  Indies,  Egypt.  Syria  and  Greece  ; 
.n  short,  we  have  fully  presented  to  us.  a body  of  authentic  statistics  bearing  upon  this  disease, — col- 
lected with  care,  and  arranged  and  classified  in  a philosophical  manner.” — The  N.  Y.  Journal  of 

Medicine. 


NEW  WORKS  AND  ^EW  EDITIONS  LATELY  PUBLISHED  BY  LEA  AND  BLANCHARD.  7 


Ellis’s  Medical  Formulary, 

NEW  AND  IMPROVED  EDITION. 

THE  MEDICAL  FORMULARY; 

Being  a collection  of  Prescriptions,  derived  from  the  writings  and  practice  of  many  of  the  most 
eminent  physicians  of  America  and  Europe.  To  which  is  added  an  appendix,  containing  the  usual 
, dietetic  preparations  and  antidotes  for  poisons.  The  whole  accompanied  with  a lew  brief  pharma- 
ceutic and  medical  observations. 

BY  BENJAMIN  ELLIS,  M.  D., 

LATE  PROFESSOR  OF  MATERIA  MEDICA  AND  PHARMACY  IN  THE  PHILADELPHIA  COLLEGE  OF  PHARMACY. 

Eighth  edition,  with  extensive  alterations  and  additions.  By  SAMUEL  GEORGE  MORTON,  M.  D. 
In  one  neat  octavo  volume. 

This  popular  work  has  been  too  extensively  and  favorably  known  to  the  profession  in  the  United 
States  to  require  any  remarks  in  introducing  a new  edition,  except  to  state  that  the  improvements  in 
it  will  be  found  to  be  numerous  and  important.  Great  care  has  been  taken  in  its  passage  through  the 
press  to  insure  the  utmost  accuracy,  and  it  is  confidently  presented  as  worthy  the  increased  confidence 
of  physicians  and  apothecaries. 


HOPE  ON  THE  HEART. — New  Edition,  just  published. 

A TREATISE  ON  THE  DISEASES 

OF  THE  HEART  AMD  GREAT  VESSELS, 

AND  ON  THE  AFFECTIONS  WHICH  MAY  BE  MISTAKEN  FOR  THEM. 

Comprising  the  author’s  view  of  the  Physiology  of  the  Heart’s  Action  and  Sounds  as  demonstrated  by 
his  experiments  on  the  Motions  and  Sounds  in  1830,  and  on  the  Sounds  in  1834—5. 

BY  J.  HOPE,  M.  D.,  F.  R.  S.,  &c.  &c. 

Second  American  from  the  third  London  edition.  With  Notes  and  a Detail  of  Recent  Experiments. 
BY  C.  W.  PENNOCK,  M.  D.,  &c. 

In  one  octavo  volume  of  nearly  six  hundred  pages,  with  lithographic  plates. 


fSWATMLi  m®©SE3  ®sr  ©HUgA1®  STSriSS’ZMSB'So 

Under  the  title  of  “ Small  Books  on  Great  Subjects,”  there  has  lately  appeared  in  London  a series  of 
works  which  have  attracted  much  attention  from  their  originality,  strength  and  conciseness.  Not- 
withstanding their  very  high  price,  they  have  commanded  a large  circulation  in  England,  while  that 
cause  has  limited  the  demand  in  this  country.  In  placing  them,  therefore,  before  the  American  public 
in  a neat  form,  and  at  the  very  low  price  of  twenty-five  cents  each,  the  American  publishers  hope  to 
meet  with  an  extended  sale.  The  following  have  appeared  : — 

No.  1.  Philosophical  Theories  and  Philosophical  Experience;  No.  2.  On  the  Connection  between 
Physiology  and  Intellectual  Science;  No.  3 On  Man’s  Power  over  himself  to  Prevent  or  Control 
Insanity;  No.  4.  An  Introduction  to  Practical  Organic  Chemistry,  with  reference  to  the  works  of 
Davy,  Brande,  Liebig,  &c. ; No.  5.  A Brief  View  of  Greek  Philosophy,  up  to  the  age  of  Pericles  ; No. 
6.  A Brief  View  of  Greek  Philosophy,  from  the  Age  of  Socrates  to  the  Coming  of  Christ ; No.  7.  Chris- 
tian Doctrine  and  Practice  in  the  Second  Century;  No.  8.  An  Exposition  of  Vulgar  and  Common 
Errors  adapted  to  the  year  of  Grace  MDCCCXLV ; No  9 An  Introduction  to  Vegetable  Physiology, 
with  References  to  the  Works  of  De  Candolle,  Lindley,  &c.  No  10.  On  the  Principles  of  Criminal 
Law.  No.  11.  Christian  Sects  in  the  Nineteenth  century. 

To  be  Continued. 


NOW  READY.— PHILOLOGY  OF  THE  EXPLORING  EXPEDITION. 

The  Ethnography  and  Philology 
OF  THE  U.  S.  EXPLORING  EXPEDITION, 

Under  the  Command  of  Captain  Wilkes,  during  the  years  1838,  1839,  1840,  1841  and  1842. 

BY  HORATIO  HALE,  Philologist  to  the  Expedition. 

In  one  large  imperial  quarto  volume,  done  up  with  great  strength  in  extra  cloth,  price  only  $10. 

This  is  the  only  edition  of  this  volume,  of  which  but  few  copies  have  been  printed  Early  ap- 
plication is  therefore  necessary  to  secure  it.  It  is  printed  and  arranged  to  match  the  Congress 
copies  of  the  “Narrative,”  and  is  confidently  presented  as  the  most  beautiful  specimen  of  typo- 
graphy ever  executed  in  this  country. 

This  work  forms  the  seventh  volume  of  the  Publications  of  the  Exploring  Expedition.  The  next 
volume,  by  Professor  Dana,  on  Corals,  with  an  Atlas  of  colored  plates,  will  shortly  be  ready,  to  be 
followed  by  the  remainder  of  the  scientific  portion. 


8 


LEA  & BLANCHARD’S  NEW  PUBLICATIONS. 


THE  GREAT  SURGICAL  LIBRARY 

(NEARLY  COMPLETED). 

CHEUUS’  SYSTEM  OF  SURGERY. 

A SYSTEM  OF  SURGERY. 

BY  J.  M.  CHELIUS, 

Doctor  in  Medicine  and  Surgery,  Public  Professor  of  General  and  Ophthalmic  Surgery,  etc.  etc.  in  the 

University  of  Heidelberg. 

TRANSLATED  FROM  THE  GERMAN, 

AND  ACCOMPANIED  WITH  ADDITIONAL  NOTES  AND  OBSERVATIONS, 

BY  JOHN  F.  SOUTH, 

SURGEON  TO  ST.  THOMAS’  HOSPITAL. 

Orbited,  toil!)  Reference  to  American  ^ntlicriiies, 

BY  GEORGE  W.  NORRIS,  M.  D. 

To  be  complete  in  Three  large  Octavo  Volumes  of  about  Six  Hundred  very  large  pages  each , or 
in  Seventeen  Numbers  at  Fifty  Cents. 

The  completion  of  this  great  work  has  been  delayed  by  the  very  numerous  and  important 
additions  of  the  translator:  it  is  now,  however,  in  a state  to  enable  the  publishers  to  pro- 
mise its  conclusion  by  the  first  of  March,  1847. 

It  is  unnecessary  to  call  the  attention  of  the  profession  to  this  important  work.  The 
names  which  are  associated  in  it,  and  the  unanimous  testimony  borne  by  the  medical  press 
to  its  excellence  are  sufficient  to  prove  its  great  value.  For  fullness  and  completeness  it  is 
unapproached  by  any  work  of  the  kind  now  before  the  profession,  and  it  may,  indeed,  be 
said  to  be  the  only  real  System  of  Surgery,  embracing  both  the  Principles  and  Practice,  that 
has  appeared  since  the  days  of  Hunter.  The  consideration  which  it  has  long  enjoyed  , abroad 
may  be  estimated  from  the  fact  of  its  having  passed  through  six  editions  in  Germany,  and  its 
having  been  translated  into  no  less  than  seven  languages. 

“Judging  from  a single  number  only  of  this  work,  we  have  no  hesitation  in  saying  that,  if  the  re* 
maining  portions  correspond  at  all  with  the  first,  it  will  be  by  far  the  most  complete  and  scientific  Sys- 
tem of  Surgery  in  the  English  language.  We  have,  indeed,  seen  no  work  which  so  nearly  comes  up 
to  our  idea  of  what  such  a production  should  be,  both  as  a practical  guide  and  as  a work  of  reference, 
as  this;  and  the  fact  that  it  has  passed  through  six  editions  in  Germany,  and  been  tran«lated  into  seven 
languages,  is  sufficiently  convincing  proof  of  its  value.  It  is  methodical  and  concise,  clear  and  accu- 
rate; omitting  all  minor  details  and  fruitless  speculations,  it  gives  us  all  the  information  we  want  in 
he  shortest  and  simplest  form.”— New  York  Journal  of  Medicine. 


DRUITT’S  SURGERY.  New  Edition-- Now  Ready. 

THE 

PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY, 

By  ROBERT  DRUITT,  Surgeon. 

THIRD  AMERICAN  FROM  THE  THIRD  LONDON  EDITION. 
ILLUSTRATED  WITH  ONE  HUNDRED  AND  FIFTY-THREE  WOOD  ENGRAVINGS. 

WITH  NOTES  AND  COMMENTS 
By  JOSHUA  B.  FLINT,  M.D.,  M.M.,  S.S.,  &c.  &c. 

In  One  very  neat  Octavo  Volume  of  about  Five  Hundred  and  Fifty  Pages. 

In  presenting  this  work  to  the  American  profession  for  the  third  time,  but  little  need  be 
said  to  solicit  for  it  a continuation  of  the  favor  with  which  it  has  been  received.  The  me- 
rits which  have  procured  it  this  favor,  its  clearness,  conciseness,  and  its  excellent  arrange- 
ment, will  continue  to  render  it  the  favorite  text-book  of  the  student  who  wishes  in  a 
moderate  space  a compend  of  the  principles  and  practice  of  Surgery. 


LEA  & BLANCHARD’S  NEW  PUBLICATIONS, 


9 


JONES  ON  THE  EYE,  Now  Ready, 

THE  PRINCIPLES  AND  PRACTICE 
OF  OPHTHALMIC  MEDICINE  AND  SURGERY. 

By  T.  WHARTON  JONES,  F.R.S.,  &c.  &c. 

WITH  ONE  HUNDRED  AND  TEN  ILLUSTRATIONS. 

EDITED  BY  ISAAC  HAYS,  M.  D.,  &c. 

In  One  very  neat  Volume , large  royal  12 mo.,  with  Four  Plates , plain  or  colored,  and 
Ninety-eight  well  executed  W oodcuts. 

This  volume  will  be  found  to  occupy  a place  hitherto  unfilled  in  this  department  of  medi- 
cal science.  The  aim  of  the  author  has  been  to  produce  a work  which  should,  in  a mode- 
rate compass,  be  sufficient  to  serve  both  as  a convenient  text-book  for  students  and  a book 
of  reference  for  practitioners.  Thus,  by  great  attention  to  conciseness  of  expression,  a 
strict  adherence  to  arrangement,  and  the  aid  of  numerous  pictorial  illustrations,  he  has  been 
enabled  to  embody  in  it  the  principles  of  ophthalmic  medicine,  and  to  point  out  their  prac- 
tical application  more  fully  than  has  been  done  in  any  other  publication  of  the  same  size. 
The  execution  of  the  work  will  be  found  to  correspond  with  its  merit,  the  illustrations  have 
been  engraved  and  printed  with  care,  and  the  whole  is  confidently  presented  as  in  every 
way  worthy  the  attention  of  the  profession. 

VOGEL’S  PATHOLOGICAL  ANATOMY. 


THE 

PATHOLOGICAL  ANATOMY  OF  THE  HUMAN  BODY, 

By  JULIUS  VOGEL,  M.D.,  &c. 

TRANSLATED  FROM  THE  GERMAN,  WITH  ADDITIONS, 

By  GEORGE  E.  DAY,  M.D.,  &c. 

EUustrate'O  bp  uptoavUs  of  <©ne  ^unbreU  $latn  anti  (Eoloreti  Hngrabtngs. 

In  One  neat  Octavo  Volume. 

The  entire  absehce  of  any  English  work  on  Morbid  Anatomy,  embracing  the  recent  dis- 
coveries effected  by  chemistry  and  the  microscope,  affords  a sufficient  reason  for  the  ap- 
pearance, in  the  present  form,  of  “Vogel’s  Pathological  Anatomy  of  the  Human  Body.” 
It  forms  in  itself  a complete  treatise  on  General  Morbid  Anatomy,  and  will  shortly  be  fol- 
lowed by  a second  volume  devoted  to  the  consideration  of  pathological  changes  affecting 
special  organs.  This  translation  has  been  made  with  the  approbation  and  assistance  of  the 
author,  who  has  examined  a considerable  portion  of  the  volume  and  expressed  his  satisfac- 
tion at  the  manner  in  which  it  was  executed. 


A PRACTICAL  TREATISE 


ON 

INFLAMMATION,  ULCERATION  AND  INDURATION  OF  THE  NECK  OF  THE  UTERUS: 
WITH  REMARKS  ON  THE  VALUE  OF  LEUCORRHCEA  AND  PROLAPSUS 
UTERI  AS  SYMPTOMS  OF  THIS  FORM  OF  DISEASE. 

BY  J.  HENRY  BENNET,  M.D., 

In  One  Duodecimo  Volume,  cloth. 

“The  descriptions  of  disease  are  throughout  clear  and  concise,  the  arrangement  of  the  subject  is 
judicious  and  the  remarks  are  thoroughly  practical,  and  calculated  to  improve  the  treatment  of  a fre- 
quent and  troublesome  class  of  diseases.  In  recommending  Dr.  Bennet’s  volume,  therefore,  to  our 
readers  as  an  excellent  essay  upon  the  subject,  we  only  convey  the  impression  which  its  perusal  has 
left  upon  us.” — Dublin  Medical  Press. 


10 


LEA  & BLANCHARD’S  NEW  PUBLICATIONS. 


ROYLE’S  MATERIA  MEDICA. 

MATERIA  MEDICA  AND  THERAPEUTICS; 

INCLUDING  THE  PREPARATIONS  OF  THE  PHARMACOPOEIAS  OF 

LONDON,  EDINBURGH,  DUBLIN,  (AND  OF  THE  UNITED  STATES.) 

WITH  MANY  NEW  MEDICINES. 

BY  J.  FORBES  ROYLE,  M.D.,  F.  R.  S.f 

Late  of  the  Medical  Staff  in  the  Bengal  Army,  Professor  of  Materia  Medica  and  Therapeutics, 
King’s  College  London,  &c.  &c. 

EDITED  BY  JOSEPH  'CARSON,  M.D., 

Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy,  Jcc.  &c. 

WITH  NINETY-EIGHT  ILLUSTRATIONS. 

In  one  large  octavo  volume  of  about  700  pages. 

Being  one  of  the  most  beautiful  Medical  works  published  in  this  Country. 

No  apology  is  requisite  for  re-issuing  the  book  in  this  country.  By  the  student  attending 
upon  lectures,  as  well  as  by  practitioners,  a full  and  large  manual  like  this  cannot  but  be  re- 
ceived with  favor,  and  notwithstanding  the  large  and  valuable  works  that  have  of  late  been 
presented  to  the  profession,  its  merit  will  insure  for  it  a favorable  reception.  The  illustrations 
are  superior  to  those  heretofore  given  in  works  of  the  kind,  every  care  having  been  taken 
both  in  the  engraving  and  printing.  The  labors  of  the  editor  have  been  confined  to  the  su- 
pervision of  the  work  in  passing  it  through  the  press,  and  the  addition  of  such  matter  in  con- 
nection with  the  Pharmacopoeia  and  indigenous  Materia  Medica  of  the  United  States,  as 
would  render  the  work  fitted  for  American  students  and  practitioners. 


WILSON’S  ANATOMY.  New  Edition— Now  Ready. 

A SYSTEM  OF  HUMAN  ANATOMY, 

GENERAL  AND  SPECIAL, 

BY  ERASMUS  WILSON,  M.D., 

Lecturer  on  Anatomy,  London. 

THIRD  AMERICAN  FROM  THE  THIRD  LONDON  EDITION. 

EDITED  BY  P.  B.  GODDARD,  A.M.,  M.D., 

Professor  of  Anatomy  in  the  Franklin  Medical  College  of  Philadelphia. 

WITH  TWO  HUNDRED  AND  THIRTY-FIVE  ILLUSTRATIONS  BY  GILBERT. 

In  one  beautiful  octavo  volume  of  over  SIX  HUNDRED  large  Pog-M, 

Strongly  Bound  and  sold  at  a low  price. 

Since  the  publication  of  the  second  American  edition  of  this  work,  the  author  has  issued 
a third  in  London,  in  which  he  has  carefully  brought  up  his  work  to  a level  with  the  most 
advanced  science  of  the  day.  All  the  elementary  chapters  have  been  rewritten,  and  such 
alterations  made  through  the  body  of  the  work,  by  the  introduction  of  all  new  facts  of  inte- 
rest, illustrated  by  appropriate  engravings,  as  much  increase  its  value.  The  present 
edition  is  a careful  and  exact  reprint  of  the  English  volume,  with  the  addition  of  such  other 
illustrations  as  were  deemed  necessary  to  a more  complete  elucidation  of  the  text;  and 
the  insertion  of  such  of  the  notes  appended  to  the  last  American  edition  as  had  not  been 
adopted  by  the  author  and  embodied  in  his  text;  together  with  such  additional  information 
as  appeared  calculated  to  enhance  the  value  of  the  work.  It  may  also  be  stated  that  the 
utmost  care  has  been  taken  in  the  revision  of  the  letter-press,  and  in  obtaining  clear  and 
distinct  impressions  of  the  accompanying  cuts. 

It  will  thus  be  seen,  that  every  effort  has  been  used  to  render  this  text-book  worthy  of  a 
continuance  of  the  great  favor  with  which  it  has  been  everywhere  received.  Professors 
desirous  of  adopting  it  for  their  classes  may  rely  on  being  always  able  to  procure  editions 
brought  up  to  the  day. 

This  book  is  well  known  for  the  beauty  and  accuracy  of  its  mechanical  execution.  The 
present  edition  is  an  improvement  over  the  last,  both  in  the  number  and  clearness  of  its 
embellishments  ; it  is  bound  in  the  best  manner  in  strong  sheep,  and  is  sold  at  a price 
which  renders  it  accessible  to  all. 


LEA  & BLANCHARD’S  NEW  PUBLICATIONS. 


It 


SUPPLEMENT  TO  THE  ENCYCLOPEDIA  AMERICANA,  UP  TO  TOE  YEAR  1847. 

ENCYCLOPEDIA  AMERICANA- -Supplementary  Vol, 
A POPULAR  DICTIONARY 

OF  ARTS,  SCIENCES,  LITERATURE,  HISTORY,  POLITICS 
AND  BIOGRAPHY. 

VOL.  XIV. 

Edited  by  HENRY  VETHAKE,  LL.  D., 

Vice-Provost  and  Professor  of  Mathematics  in  the  U niversity  of  Pennsylvania,  Author  of  “A  Treatise 

on  Political  Economy.” 

In  One  large  Octavo  Volume  of  over  Six  Hundred  and  Fifty  double  columned  pages. 

The  numerous  subscribers  who  have  been  waiting  the  completion  of  this  volume  can  now 
perfect  their  sets,  and  all  who  want  a Register  of  the  Events  of  the  last  Fifteen  Years,  for 
the  Whole  World,  particularly  embracing  interesting  scientific  investigations  and  discover- 
ies, can  obtain  this  volume  separately,  price  Two  Dollars  uncut  in  cloth,  or  Two  Dollars 
and  Fifty  Cents  in  leather,  to  match  the  styles  in  which  the  publishers  have  been  selling  sets. 

Subscribers  in  the  large  cities  can  be  supplied  on  application  at  any  of  the  principal  book- 
stores; and  persons  residing  in  the  country  can  have  their  sets  matched  by  sending  a volume 
in  charge  of  friends  visiting  the  city. 

Complete  sets  furnished  at  very  low  prices  in  various  bindings. 

“The  Conversations  Lexikon  (Encyclopedia  Americana)  has  become  a household  hook  in  all  th 
Intelligent  families  in  America,  and  is  undoubtedly  the  best  depository  of  biographical,  historical,  geo- 
graphical and  political  information  of  that  kind  which  discriminating  readers  require.  There  is  in  the 
present  volume  much  matter  purely  scientific,  which  was  all  the  more  acceptable  to  us  that  it  was 
unexpected.” — Sillimari’s  Journal. 

THE  CHEMISTRY  OF  THE  FOUR  SEASONS— A NEW  WORK. 

THE  CHEMISTRY  OF  THE  FOUR  SEASONS, 

SPRING,  SUMMER,  AUTUMN  AND  WINTER. 

AN  ESSAY  PRINCIPALLY  CONCERNING  NATURAL  PHENOMENA  ADMITTING  OF 
ILLUSTRATION  BY  CHEMICAL  SCIENCE,  AND  ILLUSTRATING  PASSAGES 
OF  SCRIPTURE. 

BY  THOMAS  GRIFFITHS, 

Professor  of  Chemistry  in  the  Medical  College  of  St.  Bartholomew’s  Hospital,  &c. 

In  One  very  neat  Volume , royal  12 mo.,  of  Four  Hundred  and  Fifty  large  pages,  extra  cloth , 
illustrated  with  numerous  Woodcuts. 

“The  title-page  copied  at  the  head  of  this  article  sufficiently  expresses  the  objects  of  the  work,  and 
the  subjects  of  which  it  treats.  It  is  a token  from  the  laboratory,  designed  for  the  parlor.  The  dis- 
courses are  adapted  to  the  comprehension  of  those  not  familiar  with  the  technicalities  and  details  of 
chemistry,  and  are  written  in  a pleasing  style.  The  mechanical  execution  of  the  work  is  neat  and 
tasteful.  Altogether  it  is  a beautiful  volume.” — Buffalo  Med.  Journal. 


YOUATT  ON  THE  DOG. 

THE  DOG. 

BY  WILLIAM  YOUATT. 

WITH  NUMEROUS  AND  BEAUTIFUL  ILLUSTRATIONS. 

EDITED  BY  E.  J.  LEWIS,  M.D.,  &c.  &c. 

In  One  beautifully  printed  Volume.  Crown  Octavo , with  Twenty-four  Plates , done  up  in 
rich  crimson  extra  cloth. 

“With  this  explanation  of  his  connection  with  the  work  he  leaves  it,  in  the  hope  that  it 
may  prove  of  value  to  the  sportsman  from  its  immediate  relation  to  his  stirring  pursuits;  to 
the  general  reader  from  the  large  amount  of  curious  information  collected  in  its  pages;  and 
to  the  medical  student  from  the  light  it  sheds  on  the  pathology  and  diseases  of  the  dog,  by 
which  he  will  be  surprised  to  learn  how  many  ills  that  animal  shares  in  common  with  th© 
human  race.” — Editor’s  Preface. 

A 


12 


VALUABLE  WORKS  PUBLISHED  BY  LEA  AND  BLANCHARD. 


Valuable  Works  for  Sportsmen,  &c, 

THE  HORSE, 

BY  WILLIAM  YOCATT. 

A NEW  EDITION,  WITH  NUMEROUS  ILLUSTRATIONS.  TOGETHER  WITH  A 

HISTORY  ©F  THE  [MIO^SIEb 

A DISSERTATION  ONTHE  AMERICAN  TROTTING  HORSE 

HOW  TRAINED  AND  JOCKEYED.  AN  ACCOUNT  OF  HIS  REMARKABLE  PERFORMANCES  ) 

AND  AN  ESSAY  ON  THE  ASS  AND  THE  MULE, 

BY  J.  S.  SKINNER, 

ASSISTANT  POST-MASTER  GENERAL,  AND  EDITOR  OF  THE  TURF  REGISTER. 

This  edition  of  Youatt’s  well-known  and  standard  work  on  the  Management,  Diseases  and 
Treatment  of  the  Horse,  has  already  obtained  such  a wide  circulation  throughout  the  country; 
that  the  Publishers  need  say  nothing  to  attract  to  it  the  attention  and  confidence  of  all  who 
keep  Horses  or  are  interested  in  their  improvement. 

STABLE  TALK  AND  TABLE  TALK, 

OR  SPECTACLES  FOR  YOUNG  SPORTSMEN. 

BY  HARRY  HIEOVER. 

In  one  very  neat  duodecimo  volume,  extra  cloth. 


THE  SPORTSMAN’S  LIBRARY, 

OR  HINTS  ON  HUNTERS,  HUNTING,  HOUNDS,  SHOOTING,  GAME,  DOGS,  GUNS,  FISHING, 

COURSING,  Ac.,  Ac. 

In  one  well  printed  volume,  duodecimo,  extra  cloth. 

EVERY  MAN  HIS  OWN  FARRrER ; 

CONTAINING  THE  CAUSES,  SYMPTOMS  AND  MOST  APPROVED  METHODS  OF  CURE  OF  THE 

DISEASES  OF  HORSES. 

BY  FRANCIS  CLATER, 

AUTHOR  OF  “ EVERY  MAN  HIS  OWN  CATTLE  DOCTOR.” 

AND  HIS  SON  JOHN  CLATER. 

First  American  from  the  twenty-eighth  London  edition,  with  notes  and  additions,  by  J.  S.  Skinner  In  one 

l*2mo.  volume,  cloth. 


EVERY  MAN  HIS  OWN  CATTLE  DOCTOR. 

CONTAINING  THE  CAUSES,  SYMPTOMS  AND  TREATMENT  OF  ALL  DISEASES  INCIDENT  TO 
OXEN,  SHEEP  AND  SWINE;  AND  A SKETCH  OF  THE  ANATOMY  AND  PHYSI- 
OLOGY OF  NEAT  CATTLE.— By  FRANCIS  CLATER. 

Edited,  Revised,  and  almost  Rewritten,  by  William  Youatt.  With  numerous  Additions,  embracingan  Essay 
on  the  Use  of  Oxen,  and  the  Improvement  in  the  Breed  of  Sheep,  by  J.  S.  Skinner,  Asst.  P.  M General. 

In  one  duodecimo  volume,  cloth,  with  numerous  illustrations. 


Kirby  and  Spence’s  Entomology,  for  Popular  Use. 

AN  INTRODUCTION  TO  ENTOMOLOGY; 

OR,  ELEMENTS  OF  THE  NATURAL  HISTORY  OF  INSECTS;  COMPRISING  AN  ACCOUNT  OF 
NOXIOUS  AND  USEFUL  INSECTS,  OF  THEIR  METAMORPHOSES,  FOOD.  STRATAGEMS, 
HABITATIONS,  SOCIETIES,  MOTIONS,  NOISES,  HYBERNATION,  INSTINCT,  Ac.,  Ac. 

With  Plates,  Plain  or  Colored. 

BY  WILLIAM  KIRBY,  M.  A.,  F.  R.  S.  AND  WILLIAM  SPENCE,  Esa.,  F.  R.  S. 
From  the  sixth  London  edition,  which  was  corrected  and  considerably  enlarged.  In  one 
large  octavo  volume,  extra  cloth. 

We  have  been  greatly  interested  in  running  over  the  pages  of  this  treatise.  There  is  scarcely,  in  the  wide 
range  of  natural  science,  a more  interesting  or  instructive  study  than  that  of  insects,  or  one  that  is  calculated 
to  excite  more  curiosity  or  wonder. 

The  popular  form  of  letters  is  adopted  by  the  authors  in  imparting  a knowledge  of  the  subject,  which  ren- 
ders the  work  peculiarly  fitted  for  our  district  school  libraries,  which  are  open  to  all  ages  and  classes.—  Hunt's 
Merchants'  Magazine. 


VALUABLE  WORKS  PUBLISHED  BY  LEA  AND  BLANCHARD. 


13 


CAMPBELL’S  LORD  CHANCELLORS. 

JUST  PUBLISHED. 

LIVES  OF  THE  LORD  CHANCELLORS  AND  KEEPERS  OF  THE 
GREAT  SEAL  OF  ENGLAND, 

FROM  THE  EARLIEST  TIMES  TO  THE  REIGN  OF  KING  GEORGE  IV., 

BY  JOHN  LORD  CAMPBELL,  A.  M.,  F.  R.  S.  E. 

First  Series,  forming  three  neat  volumes  in  demy  octavo,  extra  cloth. 

Bringing  the  work  to  the  time  of  Lord  Jeffries. 

The  second  series  will  shortly  follow  in  three  volumes  to  match. 

It  is  sufficient  for  us  to  thank  Lord  Campbell  for  the  honest  industry  with  which  he  has 
thus  far  prosecuted  his  large  task,  the  general  candor  and  liberality  with  which  he  has 
analyzed  the  lives  and  characters  of  a long  succession  of  influential  magistrates  and  min- 
isters, and  the  manly  style  of  his  narrative.  We  need  hardly  say  that  we  shall  expect  with 
great  interest  the  continuation  of  this  performance.  But  the  present  series  of  itself  is  more 
than  sufficient  to  give  Lord  Campbell  a high  station  among  the  English  authors  of  his  age. 
— Quarterly  Rev. 

The  volumes  teem  with  exciting  incidents,  abound  in  portraits,  sketches  and  anecdotes, 
and  are  at  once  interesting  and  instructive.  The  work  is  not  only  historical  and  biographi- 
cal, but  it  is  anecdotal  and  philosophical.  Many  of  the  chapters  embody  thrilling  incidents, 
while  as  a whole,  the  publication  may  be  regarded  as  of  a high  intellectual  order. — Inquirer. 

A work  in  three  handsome  octavo  volumes,  which  we  shall  regard  as  both  an  ornament 
and  an  honor  to  our  library.  A History  of  the  Lord  Chancellors  of  England  from  the  insti- 
tution of  the  office,  is  necessarily  a History  of  the  Constitution,  the  Court,  and  the  Jurispru- 
dence of  the  Kingdom,  and  these  volumes  teem  with  a world  of  collateral  matter  of  the  live- 
liest character  for  the  general  reader,  as  well  as  with  much  of  the  deepest  interest  for  the  pro- 
fessional or  philosophical  mind. — Saturday  Courier. 

A work  of  enduring  interest,  as  well  from  the  signal  ability  with  which  it  is  written,  as 
from  the  great  names  whose  personal  history  and  official  acts  it  enumerates. — Richmond 
Whig. 


HAWKER  ON_  SHOOTING. 

INSTRUCTIONS  TO  YOUNG  SPORTSMEN  IN  ALL  THAT  RE- 
LATES TO  GUNS  AND  SHOOTING. 

BY  LIEUT.  COL.  P.  HAWKER. 

From  the  enlarged  and  improved  ninth  London  edition. 

To  which  is  added  the  Hunting  and  Shooting  of  North  America , with  Descriptions  of  Animals  and  Birds. 

Carefully  collated  from  authentic  sources. 

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